A nurse in the ICU is planning the care of a patient who is being treated for shock. Which of the following statements best describes the pathophysiology of this patient's health problem?

To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform?

A patient who has been involved in a motor-vehicle crash is admitted to the ED with cool, clammy skin, tachycardia, and hypotension. All of these orders are written. Which one will the nurse act on first?

The client is admitted to the hospital with two of the systemic inflammatory response system (SIRS) variables: T: 95° F and high white blood cell count. What is the priority of care for the patient?

A 20-year-old male client arrives at the emergency department. He is conscious, coherent, and ambulatory, but his shirt and pants are covered with blood. He and his hysterical friends are yelling and trying to explain that they were playing around and he got poked in the abdomen with a stick. Which of the following comments should be given first consideration?

A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature 102° F (38.9° C), and severe back pain. Which physician order will the nurse implement first?

The triage nurse has four clients arrive in the emergency department at the same time. List the order in which the RN will assess these clients from first priority to last priority.

1. A 50-year-old female with moderate abdominal pain and occasional vomiting
2. A 35-year-old jogger with a twisted ankle, having a pedal pulse and no deformity.
3. An ambulatory dazed 25-year-old male with a bandaged head wound.
4. 4. An irritable 3-day old with a fever, petechiae, and nuchal rigidity.

The nurse in trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?

A nurse in the ICU is planning the care of a patient who is being treated for shock. Which of the following statements best describes the pathophysiology of this patient's health problem?

A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?

A client was the driver of a compact automobile that had an impact on the driver's side; he wasn't wearing a seat belt at the time of the crash. He sustained severe abdominal injuries, bilateral fractured femurs, and a 4-cm laceration to the right arm. On arrival to the emergency department, the client was pale, diaphoretic, and talking incoherently. Vital signs on arrival were blood pressure, 50/40 mm Hg; heart rate, 130 beats/minute; respiratory rate, 36 breaths/minutes; and tympanic temperature, 98.2°F (36.8° C). This client has which type of shock?