Patient Data

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The nurse recognizes that

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, and

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items that warrant follow-up.

The nurse is preparing to start an IV infusion of 1,000 mL of 0.9% sodium chloride with 30 mEq of potassium chloride for a client with diabetic ketoacidosis (DKA). Before implementing the prescription, which assessment finding is most important for the nurse to obtain?

A client's telemetry monitor indicates the sudden onset of ventricular fibrillation (VF). Which assessment finding should the nurse anticipate?

A client who experiences multiple traumatic injuries begins to ooze blood from an injection site. Which additional finding should the nurse identify that supports an early indication of disseminated intravascular coagulation (DIC)?

Patient Data

During the central line placement, the healthcare provider (HCP) gives the nurse a sample of blood to send to the laboratory.
Which 4 laboratory values would be most important to monitor this client's condition?

A client is admitted to the intensive care unit with multisystem organ dysfunction syndrome (MODS). The client is restless, febrile, and nauseated. Insulin is infusing at 5 units/hour per protocol to keep blood glucose less than 150 mg/dL (8.3 mmol/L). Dopamine is infusing at 5 mcg/kg/minute per protocol to keep mean arterial pressure (MAP) greater than 65 mm Hg. Serum blood glucose is 160 mg/dL and MAP is 66 mm Hg. The client is receiving oxygen at 50% via face mask and has an oxygen saturation of 92%. Which intervention should the nurse implement?

Reference Range:

• Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

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 is admitted to the intensive care unit (ICU) with increasing shortness of breath due to a pulmonary embolism (PE). Which finding should the nurse immediately report to the healthcare provider (HCP)?

Reference Range:

• Central venous pressure (CVP) [2 to 14 cm H2O]

A client diagnosed with pancreatitis reports severe epigastric pain. After administering a narcotic analgesic, the client insists on sitting up and leaning forward. Which action should the nurse implement?

A client who had an anterior wall myocardial infarction (MI) and a coronary artery bypass surgery one year ago is admitted to the intensive care unit (ICU) with severe shortness of breath and hemoptysis. Routine medications include an angiotensin-converting enzyme inhibitor, diuretic, anticoagulant, and potassium supplements. Vital signs are a temperature of 97.6° F (36.4° C) orally heart rate 108 beats/minute, respiratory rate 28 breaths/minute, blood pressure 96/70 mm Hg, and oxygen saturation 89% on room air. Which assessment findings should the nurse expect to find next?

The nurse is caring for a client who arrives to the emergency department (ED) with reports of experiencing dizziness and difficulty walking to the bathroom. The nurse observes right sided weakness and sluggish enunciation of speech. After obtaining vital signs, the nurse should implement which intervention?