The nurse is assessing a hospitalized client with pulmonary edema who is reporting two pillow orthopnea and paroxysmal nocturnal dyspnea. The nurse observes rapid shallow respirations and use of accessory muscles. Which action should the nurse include in the client's plan of care?

A client was admitted to the cardiac observation unit 2 hours ago reporting chest pain. On admission, the client's electrocardiogram (ECG) displays sinus bradycardia (SB) with ST segment depression, but no ventricular ectopy. The client suddenly reports a sharp increase in pain, telling the nurse, "I feel like an elephant just stepped on my chest." The ECG now displays Q waves and ST segment elevations in the anterior leads. Which interventions should the nurse perform?

Based on this rhythm strip, which interpretation should the nurse make?

An adult male is admitted with dyspnea on exertion, persistent cough, and palpitations. His telemetry reveals atrial fibrillation. Which additional assessment finding warrants the most immediate intervention by the nurse?

A client in the emergency department (ED) has baseline arterial blood gas (ABG) of pH 7.35, PaCO2 60 mm Hg, HCO3-35 mEq/L and PaO2 60 mm Hg. Which interpretation should the nurse conclude when analyzing these findings?

Reference Ranges:

• Arterial Blood Gas
• pH [7.35 to 7.45]
• PaCO2 [35 to 45 mm Hg]
• HCO3- [21 to 28 mEq/L (21 to 28 mmol/L)]
• PaO2 [80 to 100 mm Hg]

A client who had a percutaneous coronary intervention (PCI) two weeks ago returns to the clinic for a follow up visit. The client has a postoperative ejection fraction of 30%. Today the client has lungs which are clear, +1 pedal edema, and a 5 pound weight gain. Which intervention should the nurse implement?

A client's radial heart rate suddenly increases from 82 to 112 beats/minute with a 1+ pulse volume. Which assessment should the nurse complete next?

A client collapses while ambulating in the hallway. The nurse calls for help after verifying that the client is not breathing and has no palpable pulse. Which intervention should the nurse implement?

The nurse is reviewing laboratory values of a client who was discharged two weeks ago after experiencing a myocardial infarction. Which finding most requires follow-up with the client?

Reference Range:

• Triglycerides [40 to 160 mg/dL (0.45 to 1.81 mmol/L)]
• Lipase [0 to 160 units/L (0 to 2.67 μkat/L)]
• Low-density lipoproteins (LDL) [less than 130 mg/dL (3.36 mmol/L)]
• High-density lipoproteins (HDL) [greater than 45 mg/dL (greater than 1.16 mmol/L)]

The nurse is assessing a client with a history of deep vein thrombosis (DVT) who is admitted for possible pulmonary embolism (PE). It is important to report which finding to the healthcare provider immediately?

After three days of persistent epigastric pain, a female client presents to the clinic. She has been taking oral antacids without relief. Her vital signs are heart rate 122 beats/minute, respirations 16 breaths/minute, blood pressure 116/70 mm Hg, and oxygen saturation 96%. The nurse obtains a 12-lead electrocardiogram (ECG). Which assessment finding is most critical?