A patient has developed signs and symptoms of septic shock following a urinary tract infection one week ago.
The healthcare provider has prescribed a sepsis protocol to be initiated.
Which intervention should the nurse prioritize in the plan of care?

A client receives a prescription for heparin 900 units/hr IV. The IV bag contains heparin 25,000 units in 500 mL of 0.45% normal saline.

How many mL/hr should the nurse program the infusion pump to deliver?

While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound.
Before reporting this finding to the healthcare provider, which of the client’s laboratory values should the nurse note?

The client is a 22-year-old female with a history of asthma.

She was diagnosed at the age of 4 years old and has 2 previous hospitalizations for asthma related symptoms at ages 14 and 16. She denies smoking but drinks alcohol 1 to 2 times a week.

She reports taking edible marijuana to relieve severe premenstrual symptoms.

She came to the emergency department when she started having difficulty breathing on a hike.

She took her usual dose of albuterol, but the symptoms did not resolve.

The client’s friend called an ambulance when they noticed her difficulty in breathing.

Click to highlight the assessment findings that require immediate follow up by the nurse.

• The client is admitted to the medical floor.
• She has mild subcostal retractions and is sitting in an upright position.
• Wheezes are noted throughout the lung fields.
• The client is pale.
• She has strong peripheral pulses that are equal bilaterally.
• Her heart rate is 122 beats/minute, blood pressure 134/85 mm Hg. Oxygen saturation is 91% on room air.

When educating a patient newly diagnosed with type 1 diabetes mellitus, the nurse explains that increased thirst is an early sign of Diabetic Ketoacidosis (DKA). What action should the nurse advise the patient to take if this sign of DKA appears?