A young male adult walks into the emergency department (ED) holding a dead poisonous snake that bit him on his right calf within the last hour. After killing the snake, he tied a tablecloth about 4 inches (10 cm) above the bite. The client is now reporting numbness and tingling from the right knee to ankle. His heart rate is 123 beats/minute, respirations 28 breaths/minute, blood pressure 86/40 mm Hg, and oxygen saturation 94% on room air. Which intervention should the nurse implement?

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.)

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?

A client has been treated for uncontrolled atrial fibrillation with cardioversion. Following the cardioversion, which assessment finding indicates to the nurse that the desired outcome was achieved?

Based on this rhythm strip, which interpretation should the nurse make?

A client diagnosed with pancreatitis reports severe epigastric pain. After administering a narcotic analgesic, the client insists on Tip sitting up and leaning forward. Which action should the nurse implement?

A client is brought to the emergency department (ED) following a motor vehicle collision with blunt trauma to the chest. Which finding should the nurse report immediately to the healthcare provider (HCP)?

An adult client with a closed head injury was admitted to the intensive care unit (ICU) one hour ago following a motor vehicle collision. The client's telemetry displays normal sinus rhythm. After placing an intraventricular cannula for intracranial pressure monitoring, the healthcare provider (HCP) prescribes protocols for IV infusions of mannitol and dopamine. Which nursing intervention has the highest priority?

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?

An adult with head and facial injuries from a motor vehicle collision is fully immobilized and has a Glasgow coma score of 6. The client is intubated, sedated, and is being prepared for transfer to a regional trauma center. Which intervention(s) should the nurse implement? Select all that apply.

A female client admitted with possible pneumonia and systemic inflammatory response syndrome (SIRS) is manifesting low oxygen saturation rates. Which additional finding(s) associated with SIRS should the nurse report to the health care provider (HCP)? Select all that apply.

Reference Range

• White Blood Cell [5,000 to 10,000/mm3 (5 to 10 10/L)]
• Hemoglobin [12 to 16 g/dL (7.45 to 9.93 mmol/L)]