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?

A client is admitted to the intensive care unit (ICU) with sepsis and acute respiratory distress syndrome (ARDS). The client is orally intubated and mechanically ventilated. Which intervention is most important for the nurse to include in the client's plan of care (POC)?

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]

A client is admitted to the intensive care unit (ICU) after a colon resection with the formation of a loop colostomy. The nurse determines the client's abdominal dressing is clean and dry. Vital signs are temperature 100° F (37.8° C) orally, heart rate 132 beats/minute, blood pressure 88/65 mm Hg, and urine output 10 mL/hour. 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?

The nurse is administering low dose dopamine to a client who is in septic shock. Which physiologic parameter should the nurse use to evaluate a therapeutic response to the dopamine?

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

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 healthcare provider (HCP) changes a prescription for a nitroglycerin IV infusion from 10 mcg/min to 15 mcg/min. The IV bag contains nitroglycerin 50 mg in dextrose 5% in water (DW) 250 mL. The nurse should program the infusion pump to deliver how many mL/hr? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

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 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?