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?

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 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]

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?

The nurse is administering low dose dopamine to a client who is in septic shock. Which physiologic parameter should the nurse use to evaluate a therapeutic response to the dopamine?

A client is being prepared for discharge. The client's discharge plan includes resuming the lower dose of lithium and continuing to take desmopressin in oral form. The nurse teaches the client about safety measures.

Click to indicate which client statements indicate teaching was effective related to management of diabetes insipidus and care. Each row must have only one option selected.

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 admitted to the intensive care unit (ICU) with sepsis and acute respiratory distress syndrome (ARDS). The client is orally intubated and mechanically ventilated. Which intervention is most important for the nurse to include in the client's plan of care (POC)?

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

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 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?