Physiological Integrity

Following a percutaneous coronary intervention (PCI) via the right femoral artery, a client is transferred to the cardiac step-down unit. Two hours later, the client reports new-onset, severe right flank pain. Baseline vital signs upon arrival were a blood pressure of 132/76 mm Hg and a heart rate of 74 bpm. Current vital signs reveal a blood pressure of 96/52 mm Hg and a heart rate of 118 bpm. Assessment of the femoral access site shows a dry, intact dressing with no visible hematoma, and pedal pulses remain palpable bilaterally. Based on these findings, which of the following is the priority action?

A 28-year-old client with type 1 diabetes mellitus is receiving a continuous intravenous infusion of regular insulin for diabetic ketoacidosis (DKA). After 4 hours of treatment, the client's capillary blood glucose has decreased from 550 mg/dL (30.5 mmol/L) to 220 mg/dL (12.2 mmol/L). The most recent laboratory results show a serum potassium of 3.2 mEq/L (3.2 mmol/L), serum bicarbonate of 14 mEq/L (14 mmol/L), and an arterial pH of 7.25. Which of the following nursing actions are appropriate to reduce the risk of physiological complications? Select all that apply.

A nurse is caring for a client who was admitted to the emergency department with a severe asthma exacerbation. Upon admission, the client was anxious, had a respiratory rate of 34 breaths/minute, and exhibited loud, bilateral expiratory wheezing. Reassessment two hours later reveals the client is lethargic, has a respiratory rate of 12 breaths/minute, and lung sounds are significantly diminished. Which of the following arterial blood gas (ABG) results is most consistent with the client's current presentation?

A young adult arrives at the urgent care clinic complaining of relentless vomiting for the past 24 hours after consuming undercooked seafood. The provider orders a comprehensive metabolic panel and arterial blood gas analysis. The results demonstrate a pH of 7.49, a PaCO2 of 40 mm Hg, and an HCO3- of 30 mEq/L. Which clinical condition do these values represent?

A nurse is monitoring a client who has experienced profuse fluid loss from severe acute gastroenteritis. Which of the following vital sign trends provides the earliest clinical evidence that the client is entering the compensatory stage of hypovolemic shock?

A nurse is caring for an older adult client who has right-sided hemiparesis and dysphagia following a recent cerebrovascular accident. The speech-language pathologist has cleared the client to begin a pureed diet. Which nursing action is most appropriate to ensure the client's safety and comfort during meals?

A 62-year-old client with a history of cirrhosis returns to the medical-surgical unit following a percutaneous liver biopsy. The client's pre-procedure vital signs were a blood pressure of 138/82 mmHg, a heart rate of 74 beats per minute, and a respiratory rate of 16 breaths per minute. Thirty minutes later, the nurse conducts a post-procedure assessment. Which of the following assessment findings requires the nurse's immediate intervention?

A client is receiving total parenteral nutrition (TPN) through a single-lumen peripherally inserted central catheter (PICC). The healthcare provider prescribes a scheduled dose of intravenous (IV) ciprofloxacin to treat a systemic infection. Which of the following actions is the most appropriate for the nurse to take?

An unresponsive older adult client requires comprehensive oral care during the morning hygiene routine following a massive cerebral infarction. Which action should the nurse select to ensure safe and effective care?

During a shift assessment, the nurse notes that a client with a severe intestinal infection has produced copious, watery stools for three consecutive days. The healthcare team suspects an acid-base derangement and draws an arterial blood gas (ABG) sample. Which of the following ABG parameters would confirm a diagnosis of uncompensated metabolic acidosis? Select all that apply.

A registered nurse is preparing to administer an intermittent bolus enteral feeding via a nasogastric (NG) tube to a client with dysphagia. Place the following steps in the correct chronological sequence from first to last.

A client experiencing continuous generalized tonic-clonic motor activity requires emergent administration of intravenous phenytoin. The client currently has a single 18-gauge peripheral venous catheter with a primary infusion of 5% dextrose in half-normal saline (D5 0.45% NaCl) running at 75 mL/hr. To ensure safe delivery of the anticonvulsant, which action must the nurse execute?

A nurse is caring for a client with a spinal cord injury at the T4 level. The client suddenly reports a severe, throbbing headache. The nurse notes facial flushing, diaphoresis above the level of injury, and a blood pressure of 210/110 mm Hg. To reduce the risk of a severe complication, arrange the following nursing interventions in the correct sequential order.

An adult client who recently experienced status epilepticus is prescribed intravenous phenytoin. When administering this medication, which of the following safety interventions must the nurse implement? Select all that apply.

Following a severe panic attack, a client in the emergency department exhibits rapid breathing and reports numbness in the fingers. An arterial blood gas analysis yields a pH of 7.54, a PaCO2 of 26 mm Hg, and an HCO3- of 24 mEq/L. Which primary acid-base disturbance do these results indicate?

A nurse is caring for a client with hypokalemia who has a 20-gauge peripheral intravenous (IV) catheter in the right forearm. The healthcare provider prescribes an intravenous infusion of $40\text{ mEq}$ of potassium chloride over 4 hours. The pharmacy delivers a pre-mixed bag containing $40\text{ mEq}$ of potassium chloride in $100\text{ mL}$ of $0.9\%$ sodium chloride. Which of the following is the priority nursing action?

A 45-year-old client is receiving mechanical ventilation in the intensive care unit following severe chest trauma. The morning arterial blood gas (ABG) results reveal a $pH$ of $7.29$, $PaCO_2$ of $55$ mm Hg, $HCO_3^-$ of $25$ mEq/L, and $PaO_2$ of $65$ mm Hg. The client is becoming increasingly restless, and the ventilator's high-pressure alarm is sounding continuously. Which action should the nurse take first to reduce the client's risk of further physiological decompensation?

A nurse is assessing a client who sustained a cervical spinal cord injury earlier in the day. The nurse should recognize which of the following assessment findings as physiological manifestations of neurogenic shock? Select all that apply.

An adult client with a mechanical small bowel obstruction has been receiving continuous nasogastric (NG) decompression for the past 48 hours. The nurse evaluates the client's morning laboratory and arterial blood gas (ABG) results:

Potassium: 2.6 mEq/L (2.6 mmol/L)
pH: 7.53
PaCO2: 49 mm Hg
HCO3-: 35 mEq/L
PaO2: 88 mm Hg

The client is lethargic with a respiratory rate of 10 breaths per minute and shallow chest excursion. To prevent immediate physiological decompensation, which intervention should the nurse prioritize?

A client in septic shock is receiving a continuous intravenous infusion of norepinephrine at $15 \text{ mcg/min}$ through a single-lumen central venous catheter. The client's current mean arterial pressure (MAP) is $68 \text{ mmHg}$. The healthcare provider prescribes an intermittent intravenous infusion of pantoprazole to be administered over $15 \text{ minutes}$. The nurse consults a drug reference and identifies that norepinephrine and pantoprazole are incompatible at the Y-site. Which action is the most appropriate for the nurse to take?