A client was successfully extubated after several days of sedation and mechanical ventilation and is currently receiving 40% oxygen via a face mask. While making rounds, the nurse finds the client confused and attempting to get out of bed. Current vital signs are an oral temperature 99.2°F (37.3° C), heart rate 112 beats/minutes, respirations 16 breaths/minute, blood pressure 100/70 mm Hg, and an oxygen saturation of 98%. Which intervention should the nurse implement?

A 55-year-old male client is brought to the emergency department by his spouse due to sudden weakness, dizziness, and confusion. The spouse states that the client has had persistent fatigue and nausea for the past few days but suddenly became disoriented and lethargic this morning. The client also reports severe abdominal pain and muscle cramps.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

The healthcare provider (HCP) changes a prescription for a nitroglycerin IV infusion from 10 mcg/min to 15 mcg/min. The IV bag contains nitroglycerin 50 mg in dextrose 5% in water (DW) 250 mL. The nurse should program the infusion pump to deliver how many mL/hr? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

The nurse is caring for a client with massive gastrointestinal bleeding from a gastric ulcer who received 6 units packed red blood cells (PRBCs) and 2 units fresh frozen plasma (FFP). The most recent laboratory results are a hemoglobin of 8.0 g/dL (4.96 mmol/L), platelets of 82,000/mm3 (82 X 109/L), a prothrombin time (PT) of 11.1 seconds, an international normalized ratio (INR) of 1.9, and a partial thromboplastin time (PTT) of 58 seconds. Vital signs are a heart rate of 110 beats/minute, respirations of 24 breaths/minute, a blood pressure of 80/50 mm Hg, and an oxygen saturation of 94% on 4 L/minute oxygen via nasal canula. Which intervention should the nurse implement first?

Reference Range:

• Hemoglobin [14 to 18 g/dL (8.69 to 11.17 mmol/L)]
• Platelets [150,000 to 400,000/mm3 (150 to 400 x 109/L)]
• Prothrombin time (PT) [11.0 to 12.5 seconds]
• International Normalized Ratio (INR) [0.8 to 1.1]
• Partial Thromboplastin Time (PTT) [60 to 70 seconds]

Complete the following sentence by choosing from the lists of options.

A pH level of ________ and bicarbonate (HCO3-) level of________indicate a resolution of ketoacidosis.

Based on the client's diagnosis, which results does the nurse expect in the blood gas? Select all that apply

Click to mark whether the actions are indicated, contraindicated, or nonessential for this client. Each row must have one option selected.

A client, who is 4 hours postoperative laparotomy, has rapidly increasing abdominal distention with elevated pulse and respiratory rates. The client's skin is cool and pale, and there is no change in the blood pressure. Which intervention should the nurse implement immediately?

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?

The nurse is monitoring for signs of increased intracranial pressure (ICP) in a client who attempted suicide by jumping from a tenth floor balcony. The client is intubated and mechanically ventilated. Which intervention should the nurse implement to minimize rises in ICP?

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?