Complex Care

A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse making rounds at 1545 finds that the client is complaining of a pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action first?

Packed red blood cells have been prescribed for a female client with anemia who has a hemoglobin level of 7.6 g/dL (76 mmol/L) and a hematocrit level of 30% (0.30). The nurse takes the client’s temperature before hanging the blood transfusion and records 100.6° F (38.1°C) orally. Which action should the nurse take?

The nurse is caring for a client experiencing acute lower gastrointestinal bleeding. In developing the plan of care, which priority problem should the nurse assign to this client?

The nurse is assessing the functioning of a chest tube drainage system in a client with a chest injury who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply.

1. Excessive bubbling in the water seal chamber
2. Vigorous bubbling in the suction control chamber
3. Drainage system maintained below the client’s chest
4. 50mL of drainage in the drainage collection chamber
5. Occlusive dressing in place over the chest tube insertion site
6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply.

1. Restrict fluids.
2. Assess for airway patency.
3. Administer oxygen as prescribed.
4. Place a cooling blanket on the client.
5. Elevate extremities if no fractures are present.
6. Prepare to give oral pain medication as prescribed.

A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level is 950 mg/dL (52.9 mmol/L).A continuous intravenous (IV) infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL (13.37 mmol/L). The nurse would next prepare to administer which medication?

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome?

A client is admitted to the emergency department with chest pain that is consistent with myocardial infarction based on elevated troponin levels. Heart sounds are normal. The nurse should alert the primary health care provider because the vital sign changes and client assessment are most consistent with which complication? Refer to chart.

The nurse is caring for a client with chronic kidney disease on continuous replacement renal therapy (CRRT) without the use of a hemodialysis machine. The nurse determines that which parameter is most important in ensuring success of this treatment?

The nurse is monitoring a client with a head injury for signs of increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising?

A client develops an anaphylactic reaction after receiving morphine. The nurse should plan to institute which actions? Select all that apply.

1. Administer oxygen.
2. Quickly assess the client’s respiratory status.
3. Document the event, interventions, and client’s response.
4. Keep the client supine regardless of the blood pressure readings.
5. Leave the client briefly to contact a primary health care provider (PHCP).
6. Start an intravenous (IV) infusion of D5W and administer a 500-mL bolus.

A client in shock develops a central venous pressure (CVP) of 2 mm Hg and mean arterial pressure (MAP) of 60 mm Hg. Which prescribed intervention should the nurse implement first?

A client at risk for shock secondary to pneumonia develops restlessness and is agitated and confused. Urinary output has decreased and the blood pressure is 92/68 mm Hg. The nurse minimally suspects which stage of shock based on this data?

The nurse is caring for a client hospitalized for heart failure exacerbation and suspects the client may be entering a state of shock. The nurse knows that which intervention is the priority for this client?

Which clinical findings are consistent with sepsis diagnostic criteria? Select all that apply.

1. Urine output 50 mL/hr
2. Hypoactive bowel sounds
3. Temperature of 102° F (38.9°C)
4. Heart rate of 96 beats per minute
5. Mean arterial pressure 65 mm Hg
6. Systolic blood pressure 110 mm Hg