The nurse is caring for a client with pneumonia who now develops initial signs of septic shock and multi-organ failure. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care?

Patient Data

The nurse administered tPA and conducted neurologic assessments every 15 minutes during the infusion. The tPA infusion finished and the nurse performed neurologic assessments every 30 minutes for the 6 hours following the administration. The client was noted to be stable with unchanged neurologic assessments. The nurse begins to plan care for the client's recovery and identifies interdisciplinary team members who can assist with the client's recovery.

When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse?

Before leaving the room of a client who is confused, the nurse observes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. Which action should the nurse take before leaving the room?

The client is a 49-year old who reports flu-like symptoms including fever and chest congestion for 4 days. He came to the emergency department (ED last night when he was having more difficulty breathing hat a history of one-half pack a day cigarette smoking for years. He has no significant medical or surgical history

What 2 orders should the nurse complete first?

A client reports to the clinic nurse of recently experiencing symptoms of frequent urination, hunger, and great thirst. What finding (s) would the nurse consider as most significant to report to the healthcare provider? Select all that apply.

Reference Range

Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]

Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

Hemoglobin A1C [4% to 5.9%]

Hematocrit [42% to 52% (0.42 to 0.52 volume fraction)]

Total Cholesterol [less than 200 mg/dL (less than 5.2 mmol/L)]

Patient's data

Which assessment findings require follow up by the nurse? Select all that apply.

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). What nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

A client who weighs 65 kg receives a prescription for lorazepam 44 mcg/kg IV to be administered 20 minutes before a scheduled procedure. The medication is available as "Lorazepam 2 mg/ml vial". How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

An adult client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the healthcare provider?

Reference Range:

Blood alcohol level (0 to 0.05% (0 to 10.9 mmol/L]

Lithium [0.8 to 1.2 mEq/L (0.8 to 1.2 mmol/L)]