1. A nurse on the general medical-surgical unit is caring for a client in shock and assesses the following:

Respiratory rate: 10 breaths/min

Pulse: 136 beats/min

Blood pressure: 92/78 mm Hg

Level of consciousness: responds to voice

Temperature: 101.5° F (38.5° C)

Urine output for the last 2 hours: 40 mL/hr. What action by the nurse is best?

A client in acute respiratory failure is classified as having ventilatory failure. The nurse understands that which finding is a potential extrapulmonary cause of ventilatory failure?

The client with a history of alcohol use is admitted to the hospital. Upon arrival anxiety, sweating, and tremors were noted. Now, disorientation, hallucination, and hyper-reactivity are observed. The medical diagnosis is delirium tremens. What is the priority nursing diagnosis?

Following management of a disaster, a patient care technician tells the nurse, "I keep seeing the faces of people that died when I close my eyes." What is the appropriate nursing response?

Which patient problems are most commonly encountered by the health care team in the emergency department? Select all that apply

After morning care, the nurse prepares for tracheostomy care. Which action will the nurse take? Select all that apply.

The nurse is caring for an 87-year-old client who is admitted with manifestations of shock. Which of the following findings would the nurse identify as characteristics of older adults with shock? Select all that apply

A client returns to the nursing unit following a bronchoscopy with moderate sedation and local anesthesia to the throat. The procedure was completed 30 minutes ago. Which assessment finding requires immediate nursing intervention?

Which assessment finding for a client receiving oxygen therapy with a nonrebreather mask requires the nurse to intervene immediately?

A 39-year-old client is admitted with a severely abscessed tooth. The nurse assess vital signs of BP 92/44, HR 134, RR 26, Spo2 90% on room air, temperature 38.9° C. What is the priority nursing intervention?

A 54-year-old male is 3 days postoperative following a colon resection. The nurse has delegated to the assistive personnel (AP) to obtain morning vital signs. At 8:00 AM, the AP reports that the client's oral temperature is 1018F.

Upon assessment, the nurse notes that the client is flushed and slightly diaphoretic. He appears lethargic, but responds to simple questions. His vital signs are now BP 92/42, HR 132, RR 28 and deep, and his temperature has risen to 102.6° F. Lungs are clear throughout. The surgical wound has a dressing that is moist with a moderate amount of purulent drainage.

Five minutes later, the nurse contacts the surgeon to report the abnormal findings, who prescribes:

A. Tylenol 650 mg PO prn q6h for a temperature above 101° F

B. Blood cultures x 2, taken 5 minutes apart

C. C&S of abdominal wound drainage

D. Vancomycin 750 mg IVPB over 1 hour every 24 hour

Over the next hour, the client continues to decline with a decreased level of consciousness and a temperature of 103.8° F. BP is 80/40, HR is 134, and RR is 34. The nurse calls the surgeon to report these findings and obtain orders for transfer to the ICU. When preparing for this transfer, the nurse notes that the client's O2 saturation is 87% on room air.

What is the priority nursing action?