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 had gastric bypass surgery 3 days ago is admitted to the intensive care unit (ICU) with shortness of breath and chest pain. The client has a 100% nonrebreather mask with an oxygen saturation of 88%. Which intervention should the nurse implement?

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)]

The healthcare provider (HCP) prescribes dopamine 2 mcg/kg/min IV for client who weighs 60 kg. The IV bag contains "Dopamine 400 mg in dextrose 5% in water (DW) 500 mL." The nurse should program the infusion pump to deliver how many mL/hour? (Enter numerical value only.)

Which other labs would be helpful for the treatment of diabetic ketoacidosis (DKA)? Select all that apply.

The nurse is collecting a blood sample for a mixed venous oxygen saturation (SVO2) level from the distal lumen of a pulmonary artery (PA) catheter of a client in cardiogenic shock. Which action should the nurse 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?

The nurse is evaluating a client's central venous pressure (CVP) also called right atrial pressure (RAP) readings that are trending upwards. Which nursing problem is supported by the pathophysiologic mechanism most likely causing the increases?

Based on the client's diagnosis, which results does the nurse expect in the blood gas? Select all that apply

After 15 minutes of cardiopulmonary resuscitation (CPR) and multiple defibrillations, a client has return of spontaneous circulation (ROSC) with a heart rate of 130 beats/minute and ST elevation in leads I,II, III, aVF, aVL, V5, V6. Which serum laboratory values are most important for the nurse to monitor?

The nurse is caring for a client with massive gastrointestinal bleeding from a gastric ulcer who received 6 units packed red blood cells (PRBCs) and 2 units fresh frozen plasma (FFP). The most recent laboratory results are a hemoglobin of 8.0 g/dL (4.96 mmol/L), platelets of 82,000/mm3 (82 X 109/L), a prothrombin time (PT) of 11.1 seconds, an international normalized ratio (INR) of 1.9, and a partial thromboplastin time (PTT) of 58 seconds. Vital signs are a heart rate of 110 beats/minute, respirations of 24 breaths/minute, a blood pressure of 80/50 mm Hg, and an oxygen saturation of 94% on 4 L/minute oxygen via nasal canula. Which intervention should the nurse implement first?

Reference Range:

• Hemoglobin [14 to 18 g/dL (8.69 to 11.17 mmol/L)]
• Platelets [150,000 to 400,000/mm3 (150 to 400 x 109/L)]
• Prothrombin time (PT) [11.0 to 12.5 seconds]
• International Normalized Ratio (INR) [0.8 to 1.1]
• Partial Thromboplastin Time (PTT) [60 to 70 seconds]