The client with a history of alcohol use is admitted to the hospital. Upon arrival anxiety, sweating, and tremors were noted. Now, disorientation, hallucination, and hyper-reactivity are observed. The medical diagnosis is delirium tremens. What is the priority nursing diagnosis?

The nurse is caring for a client with a pneumothorax who has a chest tube connected to a closed drainage system with suction. Which of the following actions should the nurse include in the plan of care?

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?

While suctioning a client, vagal stimulation occurs. What is the appropriate nursing action?

After morning care, the nurse prepares for tracheostomy care. Which action will the nurse take? Select all that apply.

A 65 year old male patient has experienced full-thickness electrical burns on the legs and arms. As the nurse you know this patient is at risk for the following: Select all that apply:

The doctor orders your patient to start an IV Heparin drip at 16 units/kg/hr and to administer a loading bolus dose of 60 units/kg IV before initiation of the drip. You're supplied with a Heparin bag that reads 12,500 units/250 mL. The patient weighs 198 lbs. What is the flow rate you will set the IV pump (mL/hr)?

What is the subset of sepsis in which circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality?

What is the nurse's priority action for the unconscious patient who is breathing who has been brought to the ED?

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?

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