The nurse is assessing a client with rib fractures. Which of the following findings would indicate that the client is developing a tension pneumothorax?

A client in septic shock has received 30 mL/kg of crystalloid fluid resuscitation but remains hypotensive with a MAP of 58 mm Hg. The provider orders norepinephrine (Levophed) infusion to be titrated to maintain MAP 265 mm Hg. Which nursing action is the HIGHEST priority when initiating this medication?

A nurse is caring for a patient receiving oxygen therapy via a nasal cannula at a flow rate of 3 liters per minute (LPM). The patient has chronic obstructive pulmonary disease (COPD) and is experiencing increased shortness of breath. The nurse observes the patient's oxygen saturation (SpO2) has dropped to 88%. What should be the nurse's initial action?

Based on the client's vital signs, what is the appropriate nursing action?

A 72-year-old client is admitted from a skilled nursing facility with altered mental status and a productive cough. The nurse performs an assessment and documents the following findings: Temperature 101.8°F (38.8°C), heart rate 94 beats/min, respiratory rate 24 breaths/min, blood pressure 118/72 mm Hg, and WBC count 14,200/mm3. Based on the SIRS criteria, which findings indicate this client meets criteria for systemic inflammatory response syndrome? Select all that apply.

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

A client with COPD has all of the following ABG changes from earlier today. Which change alerts the nurse to take immediate action to prevent harm?

The nurse is caring for a client with acute respiratory distress syndrome (ARDS) secondary to a chest injury. The client has crackles in the bilateral posterior lung fields, tachycardia, delayed capillary refill, decreased urine output, and the following arterial blood gas (ABG) results: pH 7.56, PaO2 51, PaCo2 58, HCO3 24, SaO2 76%. Which is the healthcare team's priority?

Which statement describes the concept of scene safety in trauma situations?

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?

A patient who has been involved in a motor vehicle crash is admitted to the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which of these prescribed interventions should the nurse implement first?