A client age 56 years is experiencing withdrawal from alcohol and is placing themselves at risk for falls by repeatedly attempting to scale the bedrails. Benzodiazepines have failed to alleviate the client's agitation, and the nurse is considering obtaining an order for physical restraints to ensure client safety. The nurse should recognize that this measure may constitute:

A patient is to receive 1000 mL of IV fluid over 4 hours. The drop factor is 15 gtt/mL. How many drops per minute should the IV be set to deliver?

NOTE

• DO NOT write the unit/s of measurement
• Enter ONLY the number
• DO NOT ROUND YOUR ANSWER

A patient is brought to the ED by a friend who states that a tree fell on the patient’s leg and crushed it while they were cutting firewood. What priority actions should the nurse perform? (Select all that apply.)

A client age 56 years is experiencing withdrawal from alcohol and is placing themselves at risk for falls by repeatedly attempting to scale the bedrails. Benzodiazepines have failed to alleviate the client's agitation, and the nurse is considering obtaining an order for physical restraints to ensure client safety. The nurse should recognize that this measure may constitute:

A patient is admitted with severe malnutrition. A central venous catheter is placed in the right subclavian vein and total parenteral nutrition (TPN) is started. For which complication should the patient be evaluated immediately after insertion of the catheter?

A 17-year-old unconscious client has been admitted to the critical care unit in critical condition after a motor vehicle crash with proxy for health care decision-making assigned to the client's parents, who are divorced. When the client's hemoglobin drops to a critical level, the medical team approaches the parents regarding permission to initiate a blood transfusion, the client's mother, a practicing Jehovah's Witness, states that her child is also against such a medical intervention. The client's father does not share his ex-wife's belief that their child would refuse the lifesaving treatment and asks that the transfusion be given. What actions can be taken by the critical care nurse to assist in addressing this ethical dilemma that clearly involves the principles autonomy and beneficence? Select all that apply.

NOTE: Select 2 responses for this question

A client with cancer pain is taking morphine for pain relief. Knowing constipation is a common side effect, what would the nurse recommend to the client?

A 45-year-old recovering heroin abuser is status post lumbar fusion and is admitted to the intensive care unit for pain management isses related to a diagnosis of degenerative disk disease and associated peripheral neuropathy. The client who is currently prescribed oxycodone/paracetamol 5 mg/325 mg two tablets every 4 hours around the clock, gabapentin 300 mg four times per day methadone 10 mg twice daily. The client is awake alert, and oriented X4 with stable vitals is able to move lower extremities bilaterally, but reports decreased sensations in feet bilaterally and reporting incisional pain as a 10 of 10 on the Numeric Rating Scale (NRS)

Select the medication that can be appropriately prescribed and administered to help address the client's addiction maintenance, and postoperative pain.

Why use a specific pain intensity scale in the critical care unit?

A patient is mechanically ventilated and is receiving enteral nutrition via a nasogastric tube. To help ensure feeding tolerance, the nurse checks residual volumes every 4 hours. During a residual check later in the shift, the nurse aspirates a total residual volume of 200 mL. What action should the nurse take next?

Which intervention would the nurse plan to use for a patient who was working on a construction site and now presents to the hospital with profuse sweating, a temperature of 104°F (40°C), patent airway, tachycardia, acute confusion, and anxiety?