The nurse is teaching the spouse of a client on mechanical ventilation about measures to prevent ventilator associated pneumonia. Which of the following statements by the family would indicate to the nurse that the family would indicate to the nurse that the family needs additional instruction?

Which assessment finding in a client in the refractory phase of shock requires immediate nursing intervention?

The nurse is teaching the spouse of a client on mechanical ventilation about measures to prevent ventilator associated pneumonia. Which of the following statements by the family would indicate to the nurse that the family would indicate to the nurse that the family needs additional instruction?

The client with a history of alcohol use is admitted to the hospital. Upon arrival anxiety, sweating, and tremors were noted. Now, disorientation, hallucination, and hyper-reactivity are observed. The medical diagnosis is delirium tremens. What is the priority nursing diagnosis?

A client is on mechanical ventilator settings that include the use of PEEP (positive end-expiratory pressure). Which finding indicates the client is developing a complication related to this therapy and requires immediate treatment?

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?

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 ICU nurse receives report on a new client being admitted with a neck injury he received while diving into a lake. The ED nurse reports that his temp is 98.2, blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that that client is probably experiencing?

The nurse is caring for a client with cardiogenic shock. Which information obtained by the nurse would best suggest the patient is developing multiple organ dysfunction syndrome (MODS)?

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?

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?