Physiological Adaptation

A client arrives at the emergency department after sustaining a large laceration with significant blood loss. The bleeding is now controlled. Which vital sign change represents the body's earliest physiological adaptation to maintain adequate tissue perfusion?

A nurse is analyzing the physiological data of a client who is $36$ hours post-operative following an exploratory laparotomy for an ischemic bowel. The client is intubated, mechanically ventilated, and has an arterial line and a central venous catheter in place. The latest assessment data reveals the following:

Based on these findings, which of the following conclusions and corresponding nursing actions are correct? (Select all that apply)

A client is admitted to the intensive care unit with severe diabetic ketoacidosis (DKA). The client is lethargic with a blood glucose of 680 mg/dL (37.7 mmol/L), a serum pH of 7.12, and a blood pressure of 82/48 mm Hg. Arrange the following collaborative nursing actions in the priority order they should be implemented.

A nurse is caring for a client who is receiving treatment for severe sepsis secondary to a perforated bowel. Upon assessment, the client is restless with cold, clammy skin. Vital signs include a heart rate of 134 beats/min, a blood pressure of 82/46 mm Hg, and a respiratory rate of 36 breaths/min with deep, rapid inspirations. The latest arterial blood gas (ABG) results are: pH 7.23, PaCO2 27 mm Hg, PaO2 84 mm Hg, and HCO3- 12 mEq/L. Based on these findings, which conclusion correctly directs the nurse's immediate priorities?

A registered nurse is evaluating a client being treated for severe bacterial pneumonia. Over the past hour, the client has become visibly agitated and restless. Current assessment parameters include a heart rate of 118 beats per minute, a respiratory rate of 32 breaths per minute, and cool, diaphoretic extremities. Arterial blood gas (ABG) analysis on room air yields the following: pH 7.50, PaCO2 26 mm Hg, PaO2 54 mm Hg, and HCO3 22 mEq/L. Which of the following is the priority nursing intervention?

A nurse is caring for a client admitted to the emergency department with a severe asthma exacerbation. Initially, the client was tachypneic with a respiratory rate of 34 breaths/min, and the initial arterial blood gas (ABG) revealed a pH of 7.50, PaCO2 of 28 mm Hg, and PaO2 of 72 mm Hg. Two hours after receiving continuous nebulized bronchodilators and intravenous corticosteroids, the client remains diaphoretic, is using accessory muscles to breathe, and has significantly diminished breath sounds bilaterally. A repeat ABG shows a pH of 7.38, PaCO2 of 42 mm Hg, and PaO2 of 64 mm Hg. Based on these findings, which of the following is the most accurate interpretation of the client's condition and the priority nursing action?

A nurse receives the shift report for a group of assigned clients on a medical-surgical trauma unit. Which client requires the nurse's immediate assessment and intervention?

A nurse is providing care for a client with a T4 spinal cord injury. The client suddenly reports a severe, pounding headache. Upon assessment, the nurse notes profuse diaphoresis on the client's face and neck, severe facial flushing, a blood pressure of 218/114 mm Hg, and a heart rate of 52 beats/min. The client has an indwelling urinary catheter in place. Arrange the following nursing interventions in the correct order of priority, from first to last.

A nurse is caring for a client admitted 12 hours ago with severe acute pancreatitis. The client's current assessment reveals pale, diaphoretic skin and a total urine output of 25 mL over the past two hours. Current vital signs are: blood pressure 84/50 mm Hg, heart rate 136 beats/min, and respiratory rate 28 breaths/min. Arterial blood gas (ABG) results show a pH of 7.28, PaCO2 of 31 mm Hg, and HCO3- of 15 mEq/L. What is the priority nursing action?

A nurse is evaluating a client who was intubated and placed on mechanical ventilation $2$ hours ago for acute respiratory failure. Current assessment findings include a heart rate of $132$ bpm, blood pressure of $86/52$ mm Hg, and cool, pale extremities. The latest arterial blood gas (ABG) results are pH $7.26$, $PaCO_2$ $62$ mm Hg, $HCO_3^-$ $25$ mEq/L, and $PaO_2$ $58$ mm Hg. Based on these assessment findings, which of the following clinical judgments and nursing actions are appropriate? Select all that apply.

An adult client is receiving care in the intensive care unit for massive gastrointestinal hemorrhage. Despite aggressive fluid resuscitation, the bleeding persists. Which assessment findings suggest that the client has entered the progressive (uncompensated) stage of hypovolemic shock? Select all that apply.

A nurse is performing a reassessment on a young adult client admitted with an acute asthma exacerbation. The client initially presented with marked tachypnea, use of accessory muscles, and loud bilateral wheezing. Thirty minutes later, the nurse observes that the client's respirations have become shallow, wheezing is no longer audible, and the client appears drowsy. Arterial blood gas (ABG) results reveal a $\text{pH}$ of $7.28$, a $\text{PaCO}_2$ of $58\text{ mm Hg}$, and an $\text{HCO}_3^-$ of $24\text{ mEq/L}$. Which of the following is the priority nursing action?

A nurse is caring for a client with a history of adrenal insufficiency who was admitted for management of severe gastroenteritis. During the most recent assessment, the client appears increasingly lethargic. Vital signs show the heart rate has trended from $82$ to $114 \text{ beats/min}$, and the blood pressure has shifted from $118/76 \text{ mm Hg}$ to $102/84 \text{ mm Hg}$. Current laboratory results indicate a serum sodium of $131 \text{ mEq/L}$ ($131 \text{ mmol/L}$), serum potassium of $5.8 \text{ mEq/L}$ ($5.8 \text{ mmol/L}$), and an arterial blood gas (ABG) revealing a $\text{pH}$ of $7.31$, $\text{PaCO}_2$ of $36 \text{ mm Hg}$, and $\text{HCO}_3^-$ of $18 \text{ mEq/L}$ ($18 \text{ mmol/L}$). Which of the following is the priority nursing intervention?

A nurse is monitoring a client who recently underwent endoscopic band ligation for bleeding esophageal varices. Which assessment findings should the nurse identify as early indicators of systemic physiological deterioration and impending hypovolemic shock? (Select all that apply.)

A client recovering from a massive anterior wall myocardial infarction is being monitored with a pulmonary artery catheter. Over the last hour, the client has become increasingly lethargic. The nurse evaluates the following hemodynamic and laboratory parameters:

- Heart rate: $118$ beats/min
- Mean arterial pressure (MAP): $54$ mm Hg
- Central venous pressure (CVP): $16$ mm Hg (Normal: $2$-$8$ mm Hg)
- Pulmonary artery wedge pressure (PAWP): $24$ mm Hg (Normal: $6$-$12$ mm Hg)
- Cardiac index (CI): $1.7$ L/min/m $^2$ (Normal: $2.5$-$4.0$ L/min/m $^2$)
- Systemic vascular resistance (SVR): $2150 \text{ dynes/sec/cm}^{-5}$ (Normal: $800$-$1200 \text{ dynes/sec/cm}^{-5}$)

Arterial blood gas (ABG) results on a $40\%$ Venturi mask reveal: pH $7.24$, PaCO $_2$ $58$ mm Hg, HCO $_3^-$ $25$ mEq/L, and PaO $_2$ $58$ mm Hg.

Based on this physiological presentation, which intervention most accurately addresses the primary pathophysiological failure?

An adult client is receiving care in the emergency department for a severe asthma exacerbation. The initial arterial blood gas (ABG) on room air indicated $\text{pH} = 7.48$, $\text{PaCO}_2 = 28 \text{ mm Hg}$, and $\text{HCO}_3^- = 23 \text{ mEq/L}$. Two hours later, the nurse observes that the client has become extremely lethargic and their respiratory effort has noticeably decreased. A follow-up ABG reveals $\text{pH} = 7.29$, $\text{PaCO}_2 = 56 \text{ mm Hg}$, and $\text{HCO}_3^- = 24 \text{ mEq/L}$. Which action is the highest priority for the nurse to take?

During the immediate postoperative period following a coronary artery bypass grafting (CABG) procedure, the client's mediastinal chest tube drainage abruptly stops. The client becomes increasingly restless and diaphoresis is noted. Which of the following subsequent clinical findings support a developing complication of cardiac tamponade? Select all that apply.

A client is recovering 24 hours post-operatively following an emergency repair of a ruptured abdominal aortic aneurysm. Due to significant intraoperative blood loss, the client required massive fluid and blood product resuscitation. The nurse assesses the client and notes a tensely distended abdomen, a sudden decrease in urine output to 12 mL/hr, and increasing peak inspiratory pressures on the mechanical ventilator. Current hemodynamic monitoring reveals a blood pressure of 84/46 mm Hg, a heart rate of 128 beats/min, and a central venous pressure (CVP) of 18 mm Hg. Which of the following is the nurse's MOST appropriate initial action?

A nurse is caring for an alert and oriented client with diabetes mellitus who reports feeling shaky and sweaty. The client's capillary blood glucose level is 55 mg/dL. Arrange the following nursing interventions in the correct order of priority.

During a clinic visit, a client reports continuous, severe vomiting over the last two days due to a gastrointestinal illness. The nurse anticipates that this prolonged loss of gastric secretions places the client at highest risk for which acid-base imbalance?