Exhibits

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

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 client is admitted to the neurological intensive care unit after having just sustained a C5 spinal cord injury (SCI). Which assessment finding for this client warrants immediate intervention by the nurse?

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]

The nurse is completing a neurological assessment on a client with a head injury. The Glasgow Coma Scale (GCS) score is 14. Which intervention 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)?

The nurse is caring for a client who has hemorrhaged postoperatively and is in an early stage of shock. Which cardiopulmonary symptoms are most indicative of progressive hypovolemic shock?

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 client is a 43-year-old male who had a surgical removal of a benign tumor from the left hemisphere of his brain. The client's estimated blood loss (EBL) is 100 mL during surgical procedure. There were no complications. Vital signs remained stable throughout the procedure. The client will be admitted to the neurological intensive care unit for monitoring.

Based on the surgical site and the nature of brain surgery, identify the most likely postoperative complication, two nursing interventions to prevent it, and two clinical assessments to monitor his recovery.

Twelve hours following orthopedic surgery on the right leg, the client begins to have acute chest pain and difficulty breathing. Which action should the nurse take first?

After an endotracheal tube (ETT) is initially placed for a client requiring mechanical ventilation, which intervention should the nurse implement first?