The nurse is caring for a client who is being admitted to the emergency department with a body temperature of 105.2" F (40.7° C). Which of the following actions should the nurse take first?

Which of the following conditions can place a client at risk for acute respiratory distress syndrome (ARDS)?

In addition to calling 911, what is the appropriate nursing response when a client calls the telehealth nurse to report being bitten on the arm by an unknown type of snake?

The nurse is triaging a 65-year-old patient who arrived at the triage area with complaints of diaphoresis, dizziness, and left-sided chest pain. What category is appropriate?

The nurse is caring for a female client who has been seen at the ED multiple times recently for sexually transmitted infections and various physical concerns. When the client's boyfriend goes for coffee, what is the priority nursing action?

An adult patient is admitted to the ICU with Acute Respiratory Distress Syndrome (ARDS). The patient has been intubated and is mechanically ventilated. The patient is becoming increasingly agitated, and the high-pressure alarm is frequently being triggered. Which of the following interventions would the nurse do first? 1.25 Points

The nurse is caring for a client with a pneumothorax who has a chest tube connected to a closed drainage system with suction. Which of the following actions should the nurse include in the plan of care?

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?

The nurse is teaching a group of staff nurses about risk factors associated with developing a pulmonary embolism. Which of the following conditions would the nurse include in the teaching? Select all that apply

1. A nurse on the general medical-surgical unit is caring for a client in shock and assesses the following:

Respiratory rate: 10 breaths/min

Pulse: 136 beats/min

Blood pressure: 92/78 mm Hg

Level of consciousness: responds to voice

Temperature: 101.5° F (38.5° C)

Urine output for the last 2 hours: 40 mL/hr. What action by the nurse is best?

The nurse is assessing a client who is in shock. Which of the following findings would indicate to the nurse that the client is entering an irreversible stage?