Physiological Integrity

A nurse is assessing a client with a severe traumatic brain injury and notes a sudden, profound decline in the level of consciousness. The client's vital signs are heart rate 44 beats/min, blood pressure 196/60 mm Hg, and irregular, shallow respirations. The nurse immediately calls out for emergency assistance. Arrange the following subsequent nursing actions in the priority order they should be performed.

A 28-year-old client is receiving a continuous intravenous (IV) infusion of regular insulin for the treatment of diabetic ketoacidosis (DKA). The most recent laboratory results reveal a serum glucose of $240\text{ mg/dL}$ ($13.3\text{ mmol/L}$), serum potassium of $3.2\text{ mEq/L}$ ($3.2\text{ mmol/L}$), and an arterial blood gas (ABG) pH of $7.28$. Which of the following actions should the nurse take to reduce the client's risk for physiological complications? Select all that apply.

A nurse is preparing to discontinue a client's non-tunneled central venous catheter (CVC) located in the right subclavian vein. To minimize the risk of a potential air embolism, arrange the following nursing actions in the correct physiological sequence. (Place the first action at the top and the final action at the bottom.)

A nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is orally intubated and receiving mechanical ventilation. The ventilator is set with a fraction of inspired oxygen ($FiO_2$) of 0.60 and a positive end-expiratory pressure (PEEP) of 12 cm $H_2O$. The most recent arterial blood gas (ABG) analysis indicates a $pH$ of 7.28, $PaCO_2$ of 58 mm Hg, $HCO_3^-$ of 26 mEq/L, and $PaO_2$ of 52 mm Hg. Suddenly, the client becomes severely agitated, begins "bucking" the ventilator, and the high-peak pressure alarm sounds continuously. To reduce the immediate risk of barotrauma and physiological decompensation, which of the following actions should the nurse perform first?

An unresponsive client with a known history of severe hypothyroidism is brought to the emergency department by paramedics. Initial assessment reveals a core body temperature of 94.2°F (34.6°C), a heart rate of 46/min, a blood pressure of 80/48 mm Hg, and shallow respirations at 8/min. Arterial blood gas analysis demonstrates a pH of 7.24, PaCO2 of 58 mm Hg, HCO3 of 24 mEq/L, and PaO2 of 62 mm Hg. Which of the following is the priority nursing action?

A client is receiving a continuous intravenous regular insulin infusion and 0.9% sodium chloride for the treatment of diabetic ketoacidosis (DKA). Over the past four hours, the client's blood glucose level has decreased from 580 mg/dL to 240 mg/dL. The client suddenly reports profound muscle weakness and a fluttering sensation in the chest. The cardiac monitor displays a new onset of frequent premature ventricular contractions (PVCs). The most recent arterial blood gas analysis reveals a pH of 7.31, PaCO2 of 36 mm Hg, and HCO3 of 16 mEq/L. Which action should the nurse take immediately?

A nurse is monitoring a client who was admitted with severe acute pyelonephritis. Which of the following assessment findings would indicate that the client is entering the early, hyperdynamic phase of septic shock? Select all that apply.

A 56-year-old client with a mechanical small bowel obstruction has been receiving continuous high wall nasogastric (NG) suction for the past 3 days. The client is currently lethargic, reports severe generalized muscle weakness, and has a respiratory rate of 10 breaths/min. An arterial blood gas (ABG) panel reveals a pH of 7.54, $PaCO_2$ of 48 mmHg, and $HCO_3^-$ of 34 mEq/L. The client is currently resting in a flat, supine position. Which immediate action should the nurse take to reduce the client's risk for further physiological decompensation?

A nurse is evaluating a client who underwent a right-sided pneumonectomy 24 hours ago for bronchogenic carcinoma. The client suddenly exhibits extreme restlessness, a heart rate of 122 bpm, and a respiratory rate of 30 breaths/min. The pulse oximeter reads 87% on supplemental oxygen. Arterial blood gas (ABG) analysis indicates a pH of $7.28$, $PaCO_2$ of $62$ mm Hg, and $PaO_2$ of $54$ mm Hg. Upon entering the room, the nurse observes the client lying in a left lateral decubitus position. Which immediate action should the nurse implement to minimize the risk of impending cardiopulmonary collapse?

During the night shift, an older adult client who underwent a right total hip arthroplasty (posterior approach) 24 hours ago becomes acutely agitated. The client attempts to climb over the side rails and repeatedly insists on walking to the bathroom to have a bowel movement. Which action represents the most appropriate nursing intervention?

An intubated client with a severe exacerbation of asthma is receiving volume-controlled mechanical ventilation in the intensive care unit. The ventilator's high peak inspiratory pressure (PIP) alarm begins sounding continuously. Upon rapid assessment, the nurse notes absent breath sounds over the right lung field, prominent tracheal deviation to the left, and subcutaneous emphysema over the right anterior chest. Hemodynamic monitoring indicates a precipitous drop in blood pressure from 124/76 mm Hg to 78/38 mm Hg and a heart rate increase to 142 beats/min. A recent arterial blood gas (ABG) report shows a pH of 7.29, PaCO2 of 62 mm Hg, and HCO3 of 26 mEq/L. Which of the following is the nurse's immediate priority action?

During a shift assessment of a client recovering from an exploratory laparotomy 48 hours ago, the client coughs violently. The nurse witnesses the surgical incision suddenly separate, revealing protruding loops of intestine. Arrange the following interventions in the correct chronological sequence to prioritize client safety.

A nurse is caring for a client who is 4 days postoperative following an exploratory laparotomy. The client experiences a severe coughing episode and reports a sudden "tearing" sensation in the abdomen. Upon inspection, the nurse observes a portion of the small intestine protruding through the surgical incision. Place the following nursing actions in the correct chronological order to minimize the risk of tissue ischemia and further complications.

A client is recovering on the surgical unit 12 hours after a total abdominal hysterectomy. The nurse evaluates the client's vital sign trends over the past four hours. The heart rate has steadily risen from 82 to 118 beats per minute. The blood pressure has changed from 126/78 mm Hg to 112/90 mm Hg. The client is awake but appears restless and complains of intense thirst. Which action should the nurse implement first?

A nurse is preparing a prescribed intramuscular dose of a medication that is supplied as a dry powder in a sterile vial. The medication requires reconstitution with bacteriostatic water before administration. In what chronological sequence should the nurse perform the following actions to safely prepare the medication?

A client admitted with decompensated heart failure weighing $198\text{ lb}$ is prescribed a continuous intravenous infusion of milrinone at $0.5\text{ \mu g/kg/min}$. The pharmacy dispenses a premixed bag containing $20\text{ mg}$ of milrinone in $100\text{ mL}$ of $0.9\%$ sodium chloride. The nurse should set the infusion pump to deliver how many $\text{mL/hr}$? (Round the answer to the nearest tenth.)

A hospitalized client with an acute exacerbation of congestive heart failure experiences significant respiratory distress and exhaustion when attempting to consume lunch. Which intervention should the nurse implement to best support the client's comfort and ability to eat?

A client is admitted to the progressive care unit with suspected bowel perforation and peritonitis. The nurse assesses the client and notes a Glasgow Coma Scale score of 12, cool and mottled extremities, and a capillary refill time of 5 seconds. Vital signs include a heart rate of 132 beats/min, a respiratory rate of 28 breaths/min, and a blood pressure of 82/40 mm Hg. Arterial blood gas (ABG) results reveal a pH of 7.26, PaCO2 of 30 mm Hg, PaO2 of 74 mm Hg, and HCO3 of 14 mEq/L. Based on these physiological findings, which intervention should the nurse prioritize?

The nurse is changing the intravenous tubing on a client's central venous catheter. During the procedure, the client suddenly gasps for air, grasps their chest, and becomes cyanotic. Arrange the following nursing actions in the correct priority sequence.

A client with severe Crohn's disease is receiving a continuous infusion of total parenteral nutrition (TPN) through a single-lumen peripherally inserted central catheter (PICC). The healthcare provider prescribes intermittent intravenous (IV) ceftriaxone $1\text{ g}$ every $12\text{ hours}$. Which action represents the safest practice for administering this antibiotic?