An adult female client presents to the emergency department (ED) reporting epigastric discomfort. The client reports shortness of breath and fatigue for the past two days. Which action should the nurse implement first?

Patient Data

Following the healthcare provider's diagnosis of systemic inflammatory response syndrome (SIRS), the nurse is considering client's risk factors.

Drag one condition and one finding to complete the sentence.

The nurse recognizes that the systemic inflammatory response syndrome (SIRS) has a high risk of transitioning to

An adult who fell 20 feet (6 meters) from a tree is admitted to the intermediate intensive care unit with a fractured femur. When the cardiac monitor alarms, the nurse finds the client has no palpable carotid pulse and no spontaneous respiration, however, the cardiac monitor displays a sinus rhythm. Which intervention should the nurse implement?

Following a motor vehicle collision, an unconscious client is admitted to the emergency department (ED) via ambulance. Vital signs on arrival are heart rate 100 beats/minute, respirations 16 breaths/minute, and blood pressure 130/76 mm Hg. The nurse plans to monitor the client for complications associated with a basilar skull fracture. Which finding confirms this complication?

A client who is admitted to the emergency department (ED) following a motorcycle collision is having difficulty breathing. While assessing the client's chest and lungs, the nurse notes that there are no breath sounds over the left lung fields. Which action(s) should the nurse implement? Select all that apply.

An adult male is admitted to the cardiovascular intensive care unit (CV-ICU) following an acute myocardial infarction (AMI). His wife is at the bedside when the client goes unresponsive, the monitor alarms and displays ventricular fibrillation (VF). The resuscitation team rushes into the client's room and when the wife is asked to wait in the waiting area, she refuses to leave. Which action should the nurse take?

A client with a femoral arterial sheath is admitted to the cardiac care unit (CCU) after a percutaneous transluminal coronary angioplasty (PTCA). Which intervention should the nurse provide during the first hour of postoperative care?

The nurse is caring for a client with pericarditis after undergoing a bedside pericardiocentesis. Which finding warrants immediate intervention by the nurse?

A client admitted to the intensive care unit (ICU) with acute respiratory distress syndrome (ARDS) is intubated and placed on assist-control mechanical ventilation. When suctioning pulmonary secretions from the endotracheal tube (ETT) using a closed suction system, which action should the nurse implement to ensure that the client receives adequate oxygenation?

A client who was admitted because of a spontaneous pneumothorax has a chest tube placed to water seal drainage. The nurse auscultates all lung fields to evaluate the effectiveness of therapy. Which computer documentation indicates that atelectasis is resolving?

A client who sustained severe liver lacerations in a motorcycle collision is transported to the intensive care unit (ICU) following a segmental resection of the liver. One hour later, the nurse notes that the client is hemorrhaging from the surgical site. Which action should the nurse take?