As the assessment is completed, the nurse observes that the client has a large amount of thick secretions visible in the trach. What is the priority nursing action?

Which assessment finding in a client in the refractory phase of shock requires immediate nursing intervention?

The nurse is caring for a client with acute respiratory distress syndrome (ARDS) secondary to a chest injury. The client has crackles in the bilateral posterior lung fields, tachycardia, delayed capillary refill, decreased urine output, and the following arterial blood gas (ABG) results: pH 7.56, PaO2 51, PaCo2 58, HCO3 24, SaO2 76%. Which is the healthcare team's priority?

After a mass casualty event, which client will the nurse triage with a yellow tag? 1.25 Points

A patient receiving treatment for a pneumothorax calls on the call light to tell you something is wrong with their chest tube. When you arrive to the room you note that the drainage system has fallen on its side and there is a large crack in the system. What is your next PRIORITY?

The nurse is caring for a client who is being admitted to the emergency department with a body temperature of 105.2" F (40.7° C). Which of the following actions should the nurse take first?

A 32-year-old client with a history of asthma presents to the emergency department in severe respiratory distress. The client is using accessory muscles, is unable to speak in complete sentences, and has an SpO2 of 88% on room air. Peak flow measurement is 25% of predicted. Despite three consecutive nebulizer treatments with albuterol, the client shows minimal improvement. Which finding indicates the client is progressing to status asthmaticus requiring immediate escalation of care?

The nurse is caring for a client experiencing tachypnea, dyspnea, and confusion. Which of the following orders does the nurse anticipate receiving from the healthcare provider? Select all that apply

A 54-year-old male is 3 days postoperative following a colon resection. The nurse has delegated to the assistive personnel (AP) to obtain morning vital signs. At 8:00 AM, the AP reports that the client's oral temperature is 1018F.

Upon assessment, the nurse notes that the client is flushed and slightly diaphoretic. He appears lethargic, but responds to simple questions. His vital signs are now BP 92/42, HR 132, RR 28 and deep, and his temperature has risen to 102.6° F. Lungs are clear throughout. The surgical wound has a dressing that is moist with a moderate amount of purulent drainage.

Five minutes later, the nurse contacts the surgeon to report the abnormal findings, who prescribes:

A. Tylenol 650 mg PO prn q6h for a temperature above 101° F

B. Blood cultures x 2, taken 5 minutes apart

C. C&S of abdominal wound drainage

D. Vancomycin 750 mg IVPB over 1 hour every 24 hour

Over the next hour, the client continues to decline with a decreased level of consciousness and a temperature of 103.8° F. BP is 80/40, HR is 134, and RR is 34. The nurse calls the surgeon to report these findings and obtain orders for transfer to the ICU. When preparing for this transfer, the nurse notes that the client's O2 saturation is 87% on room air.

What is the priority nursing action?

What type of chest tube system does this statement describe? This chest drainage system has no water column to control suction but uses a suction monitor bellow that balances the wall suction and you can adjust water suction pressure using the rotary suction dial on the side of the system. It allows for higher suction pressure levels, has no bubbling sounds, and water does not evaporate from it as with other systems.

Which of the following interventions would be most likely to prevent the development of acute respiratory distress syndrome (ARDS)?