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A client admitted with septic shock has a temperature of 39.7°C (103.5°F), blood
pressure of 82/48 mm Hg, heart rate of 132/min, and urine output of 15 mL/hr.
Identify the highest-priority nursing problem.
Answer: Impaired tissue perfusion related to septic shock resulting in hypotension
and decreased organ perfusion. The ABCs and clinical judgment prioritize
circulation because profound hypotension threatens oxygen delivery to vital
organs. Prompt fluid resuscitation, vasopressors if prescribed, and close
monitoring are essential to prevent multiple organ dysfunction.
A client develops sudden dyspnea, chest pain, tachycardia, and oxygen saturation
of 84% after hip replacement surgery. Identify the most likely complication.
Answer: Pulmonary embolism. Recent orthopedic surgery significantly increases
the risk for deep vein thrombosis and pulmonary embolism. Sudden hypoxia,
pleuritic chest pain, and tachycardia require immediate intervention, oxygen
therapy, and rapid provider notification.
A nurse reviews laboratory findings for a client with diabetic ketoacidosis. Which
laboratory value requires immediate correction?
, Answer: Serum potassium abnormalities. Although potassium may initially appear
elevated, total body potassium is depleted. Administration of insulin causes
potassium to move into cells, potentially producing life-threatening hypokalemia
if not monitored and corrected appropriately.
A client receiving morphine intravenously becomes difficult to arouse with a
respiratory rate of 8/min. Identify the priority intervention.
Answer: Administer naloxone as prescribed and support respirations. Respiratory
depression is the most serious adverse effect of opioid administration. Reversal
with naloxone while maintaining airway patency and adequate ventilation
prevents respiratory arrest.
A client with pneumonia suddenly becomes confused. Which assessment finding
is most concerning?
Answer: Oxygen saturation of 86%. Acute confusion frequently results from
hypoxemia, especially in older adults. Restoring adequate oxygenation is the
highest priority before investigating other possible causes.
A client with heart failure gains 2.7 kg (6 lb) within three days. Identify the priority
nursing action.
Answer: Notify the provider and assess for worsening fluid overload. Rapid weight
gain reflects fluid retention rather than increased body mass. Early intervention
helps prevent pulmonary edema and worsening heart failure.
A client with gastrointestinal bleeding reports dizziness upon standing. Identify
the underlying cause.