Physiological Integrity

A client, aged 62, presents to the acute care unit following three days of severe, intractable vomiting. Upon initial assessment, the client is lethargic with pale, cool skin. Hemodynamic monitoring reveals a heart rate of 118 beats per minute, a blood pressure of 86/52 mm Hg, and a shallow respiratory rate of 10 breaths per minute. The laboratory reports the following arterial blood gas (ABG) values: pH 7.54, $PaCO_2$ 50 mm Hg, $HCO_3^-$ 36 mEq/L, and $PaO_2$ 88 mm Hg. Which action should the nurse take first to reduce the risk of further physiological deterioration?

A client is recovering in the surgical unit on the first postoperative day following a left total knee arthroplasty. The client reports mild leg discomfort and requests an adjustment to their resting position in bed. Which intervention should the nurse implement to promote comfort and prevent postoperative complications?

The emergency response team is caring for a young adult experiencing a severe asthma exacerbation. Initial assessment reveals prominent accessory muscle use, marked agitation, and loud expiratory wheezes. Baseline arterial blood gas (ABG) values on room air demonstrate a pH of $7.50$, PaCO $_2$ of $26\text{ mm Hg}$, HCO $_3^-$ of $23\text{ mEq/L}$, and PaO $_2$ of $64\text{ mm Hg}$. Following administration of intravenous methylprednisolone and continuous bronchodilator therapy, a reassessment is performed two hours later. The client is now lethargic with barely audible breath sounds. A follow-up ABG on a $40\%$ Venturi mask reveals a pH of $7.36$, PaCO $_2$ of $44\text{ mm Hg}$, HCO $_3^-$ of $24\text{ mEq/L}$, and PaO $_2$ of $54\text{ mm Hg}$. Based on these clinical findings, which action should the nurse take immediately?

A nurse is caring for a client with a serum potassium level of $2.6 \text{ mEq/L}$. The provider prescribes $20 \text{ mEq}$ of intravenous potassium chloride (KCl) diluted in $100 \text{ mL}$ of $0.9\%$ normal saline to be infused over $1 \text{ hour}$. The client has a 22-gauge peripheral IV in the right forearm and a double-lumen peripherally inserted central catheter (PICC) in the left arm. Which of the following is the most appropriate action by the nurse?

A charge nurse is observing a newly licensed nurse prepare and administer medications to assigned clients. Which of the following actions by the newly licensed nurse require immediate intervention by the charge nurse? Select all that apply.

An adult client admitted with acute decompensated heart failure requires inotropic support. The healthcare provider prescribes a continuous intravenous dobutamine infusion at a dose of $5\text{ mcg/kg/min}$. The client's current weight is $80\text{ kg}$. The medication is supplied as a pre-mixed bag containing $500\text{ mg}$ of dobutamine in $250\text{ mL}$ of $5\%$ dextrose in water. Calculate the required infusion rate in $\text{mL/hr}$. Record your answer as a whole number.

A nurse is assessing a client who was admitted 12 hours ago with deep partial-thickness and full-thickness thermal burns over 40% of their total body surface area. Which of the following clinical findings should the nurse identify as expected physiological responses during this emergent (resuscitative) phase? (Select all that apply.)

A client admitted with urosepsis has the following clinical parameters documented over a four-hour period:

What is the most accurate interpretation of these clinical findings?

An older adult client returns to the medical-surgical unit immediately following a lumbar puncture. The client appears restless, reports mild discomfort at the insertion site, and frequently reaches toward the lower back dressing. Which of the following actions should the nurse take to promote client comfort and prevent complications?

A client weighing $192 \text{ lbs}$ is receiving treatment for a stable ventricular tachycardia. The healthcare provider prescribes a continuous intravenous infusion of amiodarone at $0.5 \text{ mg/min}$. The pharmacy supplies an amiodarone infusion bag containing $900 \text{ mg}$ in $500 \text{ mL}$ of $5\% \text{ dextrose}$ in water ($D_5W$). At what rate, in $\text{mL/hr}$, should the nurse set the infusion pump? Record your answer using one decimal place.

Two nurses are preparing to move a conscious, partially mobile client up in bed using a friction-reducing draw sheet. Place the steps of this procedure in the correct chronological order.

A client is 48 hours post-operative following a right above-the-knee amputation and reports phantom limb sensations. The healthcare team is focusing on promoting optimal long-term mobility and physical comfort. Which action should the nurse implement?

A nurse is evaluating a client who is 4 hours postoperative following an open cholecystectomy. The client's vital signs upon admission to the unit were blood pressure 126/78 mm Hg, heart rate 76 beats/min, and respiratory rate 16 breaths/min. The client's current vital signs are blood pressure 112/86 mm Hg, heart rate 114 beats/min, and respiratory rate 22 breaths/min. The client reports mild abdominal aching. Which of the following is the priority nursing action?

A client with hypertensive emergency is admitted to the intensive care unit with a blood pressure of $240/130 \text{ mmHg}$. The healthcare provider prescribes a continuous intravenous infusion of sodium nitroprusside. Forty-eight hours later, the nurse notes that the client has become severely agitated and disoriented, with a respiratory rate of $28 \text{ breaths/min}$. An arterial blood gas (ABG) analysis reveals a pH of $7.25$, a $PaCO_2$ of $30 \text{ mmHg}$, and an $HCO_3^-$ of $14 \text{ mEq/L}$. Which of the following is the priority nursing action?

A nurse is caring for a client who sustained a spinal cord injury at the T4 level one month ago. The client suddenly reports a severe, pounding headache and blurred vision. The nurse observes profuse diaphoresis and flushing above the level of injury, and the blood pressure is $215/115 \text{ mmHg}$. Arrange the following nursing actions in the priority order they should be performed.

A nurse is providing discharge instructions to a client who has a cast on the right lower leg and is prescribed standard axillary crutches. The client has a strict non-weight-bearing status on the right leg. Which of the following instructions should the nurse provide regarding how to correctly ascend a flight of stairs?

A nurse is preparing to administer a scheduled dose of intravenous (IV) push metoprolol through a client's peripheral saline lock. In what order should the nurse perform the following actions? Arrange the steps in the correct chronological sequence.

A 42-year-old client with severe iron deficiency anemia is receiving a transfusion of packed red blood cells (PRBCs) on the medical-surgical unit. Fifteen minutes into the transfusion, the client suddenly reports severe lower back pain, shortness of breath, and a feeling of impending doom. The nurse observes that the client is flushed and shivering. Place the following nursing actions in the correct priority sequence.

A nurse is caring for a client on a medical-surgical unit who suddenly develops severe dyspnea, a respiratory rate of 34/min, and produces pink, frothy sputum. Crackles are auscultated throughout both lung fields. Arrange the following nursing actions in the priority order they should be performed.

A client with a documented history of advanced emphysema arrives at the emergency department exhibiting profound lethargy and a respiratory rate of 8 breaths per minute. Paramedics report initiating supplemental oxygen at 6 liters per minute via simple face mask during transport. Stat arterial blood gas (ABG) analysis reveals a pH of 7.24, PaCO2 of 78 mm Hg, PaO2 of 65 mm Hg, and HCO3 of 35 mEq/L. Which action must the nurse prioritize to minimize the client's risk for cardiopulmonary arrest?