Twelve hours following orthopedic surgery on the right leg, the client begins to have acute chest pain and difficulty breathing. Which action should the nurse take first?

A postoperative client is admitted to the intensive care unit (ICU) with an inflated pressure infuser containing a solution of heparin 2 units/ml attached to an intra-arterial (IA) cannula. Which finding indicates that the heparin infusion has achieved its therapeutic use?

The nurse is caring for a client with massive gastrointestinal bleeding from a gastric ulcer who received 6 units packed red blood cells (PRBCs) and 2 units fresh frozen plasma (FFP). The most recent laboratory results are a hemoglobin of 8.0 g/dL (4.96 mmol/L), platelets of 82,000/mm3 (82 X 109/L), a prothrombin time (PT) of 11.1 seconds, an international normalized ratio (INR) of 1.9, and a partial thromboplastin time (PTT) of 58 seconds. Vital signs are a heart rate of 110 beats/minute, respirations of 24 breaths/minute, a blood pressure of 80/50 mm Hg, and an oxygen saturation of 94% on 4 L/minute oxygen via nasal canula. Which intervention should the nurse implement first?

Reference Range:

• Hemoglobin [14 to 18 g/dL (8.69 to 11.17 mmol/L)]
• Platelets [150,000 to 400,000/mm3 (150 to 400 x 109/L)]
• Prothrombin time (PT) [11.0 to 12.5 seconds]
• International Normalized Ratio (INR) [0.8 to 1.1]
• Partial Thromboplastin Time (PTT) [60 to 70 seconds]

The nurse is monitoring for signs of increased intracranial pressure (ICP) in a client who attempted suicide by jumping from a tenth floor balcony. The client is intubated and mechanically ventilated. Which intervention should the nurse implement to minimize rises in ICP?

A client is admitted to the intensive care unit (ICU) after a colon resection with the formation of a loop colostomy. The nurse determines the client's abdominal dressing is clean and dry. Vital signs are temperature 100° F (37.8° C) orally, heart rate 132 beats/minute, blood pressure 88/65 mm Hg, and urine output 10 mL/hour. Which intervention should the nurse implement?

A client who is admitted to the intensive care unit (ICU) with acute decompensated heart failure is receiving a continuous infusion of milrinone via a subclavian venous catheter. Which action should the nurse take when preparing to administer the first dose of IV furosemide?

The nurse is evaluating a client's central venous pressure (CVP) also called right atrial pressure (RAP) readings that are trending upwards. Which nursing problem is supported by the pathophysiologic mechanism most likely causing the increases?

A 55-year-old male client is brought to the emergency department by his spouse due to sudden weakness, dizziness, and confusion. The spouse states that the client has had persistent fatigue and nausea for the past few days but suddenly became disoriented and lethargic this morning. The client also reports severe abdominal pain and muscle cramps.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Twelve hours following orthopedic surgery on the right leg, the client begins to have acute chest pain and difficulty breathing. Which action should the nurse take first?

A client is admitted to the neurological intensive care unit after having just sustained a C5 spinal cord injury (SCI). Which assessment finding for this client warrants immediate intervention by the nurse?

A young male adult walks into the emergency department (ED) holding a dead poisonous snake that bit him on his right calf within the last hour. After killing the snake, he tied a tablecloth about 4 inches (10 cm) above the bite. The client is now reporting numbness and tingling from the right knee to ankle. His heart rate is 123 beats/minute, respirations 28 breaths/minute, blood pressure 86/40 mm Hg, and oxygen saturation 94% on room air. Which intervention should the nurse implement?