The nurse identifies the collaborative problem of potential electrolyte imbalance in a client with acute pancreatitis. Which assessment finding should the nurse associate with an electrolyte imbalance related to acute pancreatitis?

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 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 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)]

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?

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 monitoring for signs of increased intracranial pressure (ICP) in a client who attempted suicide by jumping from a tenth floor balcony. The client is intubated and mechanically ventilated. Which intervention should the nurse implement to minimize rises in ICP?

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

The nurse assesses the telemetry monitor of a client who is 24 hours postoperative from having a permanent pacemaker insertion. The nurse observes that a pacemaker spike is present before each QRS complex in lead II of the electrocardiogram (ECG). Which intervention should the nurse implement?

A client has been treated for uncontrolled atrial fibrillation with cardioversion. Following the cardioversion, which assessment finding indicates to the nurse that the desired outcome was achieved?

A female client admitted with possible pneumonia and systemic inflammatory response syndrome (SIRS) is manifesting low oxygen saturation rates. Which additional finding(s) associated with SIRS should the nurse report to the health care provider (HCP)? Select all that apply.

Reference Range

• White Blood Cell [5,000 to 10,000/mm3 (5 to 10 10/L)]
• Hemoglobin [12 to 16 g/dL (7.45 to 9.93 mmol/L)]