A client who had an anterior wall myocardial infarction (MI) and a coronary artery bypass surgery one year ago is admitted to the intensive care unit (ICU) with severe shortness of breath and hemoptysis. Routine medications include an angiotensin-converting enzyme inhibitor, diuretic, anticoagulant, and potassium supplements. Vital signs are a temperature of 97.6° F (36.4° C) orally heart rate 108 beats/minute, respiratory rate 28 breaths/minute, blood pressure 96/70 mm Hg, and oxygen saturation 89% on room air. Which assessment findings should the nurse expect to find next?

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 nurse is caring for a client who had a vaginal delivery 2 hr ago. Which of the following actions should the nurse anticipate in the care of this client? (Select all that apply.)

The healthcare provider (HCP) prescribes lidocaine 4 mg/minute IV for a client experiencing premature ventricular contractions (PVCS). The IV bag contains lidocaine 1 gram in 500 mL DW. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only)

Consent is obtained to perform a diagnostic thoracentesis for a client with left side pleural effusion. The client is alert, cooperative, and anxious. The nurse should assist the client into which position immediately prior to the procedure?

Patient Data

The nurse is reviewing the assessment findings, laboratory data, and diagnostic results to consider the client's condition. Choose the most likely options for the information missing from the statement by selecting from the lists of options provided.

The nurse recognizes the client is most likely experiencing

A client with an implanted cardioverter defibrillator (ICD) reports to the home health nurse feeling dizzy when the device discharges. Which intervention is most important for the nurse to implement?

The nurse identifies the collaborative problem of potential electrolyte imbalance in a client with acute pancreatitis. Which assessment finding should the nurse associate with an electrolyte imbalance related to acute pancreatitis?

An adult client presents to the emergency department (ED) with nausea, vomiting, and mild confusion and reports having blurred vision. The cardiac telemetry monitor reveals atrial fibrillation (A-fib) with a controlled ventricular response (CVR). The client reports taking digoxin. Which intervention should the nurse implement?

A client who experiences multiple traumatic injuries begins to ooze blood from an injection site. Which additional finding should the nurse identify that supports an early indication of disseminated intravascular coagulation (DIC)?

The vital signs for a client with heart failure (HF), who is admitted to the intensive care unit (ICU), are a temperature of 96.8°F (37 C), heart rate 125 beats/minute, respirations 22 breaths/minute, and blood pressure 140/50 mm Hg. The nurse determines the client's central venous pressure (CVP) and pulmonary artery wedge pressure (PAWP) are elevated. Which intervention should the nurse implement?