The nurse in the ICU is admitting a 57-year-old man with a diagnosis of possible septic shock. The nurse's assessment reveals that the patient has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurse's analysis of these data should lead to what preliminary conclusion?

Which of the following clinical manifestations are suggestive of the systemic inflammatory response syndrome (SIRS)? Select all that apply.

A patient in septic shock has not responded to fluid resuscitation, as evidenced by a decreasing BP and cardiac output. The nurse anticipates the administration of

The healthcare provider is caring for a patient with a diagnosis of hemorrhagic pancreatitis. The patient's central venous pressure (CVP) reading is 2, blood pressure is 90/50 mmHg, lung sounds are clear, and jugular veins are flat. Which of these actions is most appropriate for the nurse to take?

A nurse is assessing an adolescent who experienced blunt trauma to the abdomen. Which of the following findings is the nurse's priority?

A 20-year-old male client arrives at the emergency department. He is conscious, coherent, and ambulatory, but his shirt and pants are covered with blood. He and his hysterical friends are yelling and trying to explain that they were playing around and he got poked in the abdomen with a stick. Which of the following comments should be given first consideration?

A nurse in the ICU receives report from the nurse in the EC about a new patient being admitted with a neck injury he received while diving into a lake. The EC nurse reports that his blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that that patient is probably experiencing?

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

A patient who was an unrestrained driver in a high-speed, head-on motor vehicle collision presents with dyspnea, tachycardia, hypotension, jugular venous distension, tracheal deviation to the left, and decreased breath sounds on the right side. What is the most likely diagnosis?

A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?

You are caring for a patient who sustained rib fractures after hitting the steering wheel of his car. He is spontaneously breathing and receiving oxygen via a face mask. His oxygen saturation is 95%. During your assessment, the oxygen saturation drops to 80%. The patient's blood pressure has dropped from 128/76 mm Hg to 84/50 mm Hg. You do not auscultate any breath sounds on the left side of the chest and you notice JVD. You notify the physician and anticipate: