A client is admitted to the critical care unit (CCU) with a third degree complete heart block. A temporary transvenous pacemaker is inserted by the healthcare provider (HCP). An hour after pacemaker insertion, the device stops sensing the client's intrinsic heart rate. Which action should the nurse implement first?

A young male adult walks into the emergency department (ED) holding a dead poisonous snake that bit him on his right calf within the last hour. After killing the snake, he tied a tablecloth about 4 inches (10 cm) above the bite. The client is now reporting numbness and tingling from the right knee to ankle. His heart rate is 123 beats/minute, respirations 28 breaths/minute, blood pressure 86/40 mm Hg, and oxygen saturation 94% on room air. Which intervention should the nurse implement?

A client is admitted to the intensive care unit with multisystem organ dysfunction syndrome (MODS). The client is restless, febrile, and nauseated. Insulin is infusing at 5 units/hour per protocol to keep blood glucose less than 150 mg/dL (8.3 mmol/L). Dopamine is infusing at 5 mcg/kg/minute per protocol to keep mean arterial pressure (MAP) greater than 65 mm Hg. Serum blood glucose is 160 mg/dL and MAP is 66 mm Hg. The client is receiving oxygen at 50% via face mask and has an oxygen saturation of 92%. Which intervention should the nurse implement?

Reference Range:

• Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

A postoperative client is admitted to the intensive care unit (ICU) with an inflated pressure infuser containing a solution of heparin 2 units/ml attached to an intra-arterial (IA) cannula. Which finding indicates that the heparin infusion has achieved its therapeutic use?

Drag one condition and one client finding to complete the sentence(s). Based on the ABG values, the nurse knows that the client has

A female client admitted with possible pneumonia and systemic inflammatory response syndrome (SIRS) is manifesting low oxygen saturation rates. Which additional finding(s) associated with SIRS should the nurse report to the health care provider (HCP)? Select all that apply.

Reference Range

• White Blood Cell [5,000 to 10,000/mm3 (5 to 10 10/L)]
• Hemoglobin [12 to 16 g/dL (7.45 to 9.93 mmol/L)]

A client admitted to the intensive care unit (ICU) with acute respiratory distress syndrome (ARDS) is intubated and placed on assist-control mechanical ventilation. When suctioning pulmonary secretions from the endotracheal tube (ETT) using a closed suction system, which action should the nurse implement to ensure that the client receives adequate oxygenation?

After an endotracheal tube (ETT) is initially placed for a client requiring mechanical ventilation, which intervention should the nurse implement first?

A client who was involved in a motor vehicle collision while riding a motorcycle without wearing a helmet, is brought the emergency department (ED) by emergency medical services (EMS). Which assessment should the nurse obtain first?

A client is being prepared for discharge. The client's discharge plan includes resuming the lower dose of lithium and continuing to take desmopressin in oral form. The nurse teaches the client about safety measures.

Click to indicate which client statements indicate teaching was effective related to management of diabetes insipidus and care. Each row must have only one option selected.

After intubating a client, correct placement of the endotracheal tube (ETT) is confirmed with a chest x-ray. Which intervention should the nurse implement to ensure that the ETT placement is maintained?