The nurse is caring for a client with severe bleeding from a wound. Which of the following intravenous solutions would the client most likely receive initially?

A client who has been mechanically ventilated for 5 days following ARDS is being evaluated for weaning readiness. The respiratory therapist reports the following parameters: Rapid shallow breathing index (RSBI) of 85, negative inspiratory force (NIF) of -28 cm H2O, spontaneous tidal volume of 6 mL/kg, and FiO2 requirement of 40% to maintain SpO2 >92%. Which parameter indicates the client may NOT be ready for weaning?

A 39-year-old client is admitted with a severely abscessed tooth. The nurse assess vital signs of BP 92/44, HR 134, RR 26, Spo2 90% on room air, temperature 38.9° C. What is the priority nursing intervention?

A client returns to the nursing unit following a bronchoscopy with moderate sedation and local anesthesia to the throat. The procedure was completed 30 minutes ago. Which assessment finding requires immediate nursing intervention?

After assessing four clients, which will the triage nurse identify to be seen first in the ED?

Which one of the following assessments is most appropriate for determining the correct placement of an endotracheal tube in a mechanically ventilated client?

Following management of a disaster, a patient care technician tells the nurse, "I keep seeing the faces of people that died when I close my eyes." What is the appropriate nursing response?

Which of the following interventions would be most likely to prevent the development of acute respiratory distress syndrome (ARDS)?

A client with COPD who smokes 1 PPD presents for a routine appointment. Which client statement causes the nurse to suspect an increase in dyspnea?

In what order will the nurse implement these interventions?

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?