Critical Care Practice Quizzlet

The nurse is analyzing an arterial blood gas of a client who is mechanically ventilated. The ABG results are pH - 7.37; paCO2 - 30 mmHg; HCO3 - 28mEq/liter. Which should the nurse recognize as a cause of these findings? A) Decreased respiratory rate causing respiratory acidosis. B) Decreased respiratory rate causing respiratory alkalosis. C) Diarrhea with a fully compensated metabolic acidosis. D) Nasogastric suction with a fully compensated metabolic alkalosis.

D) Nasogastric suction with a fully compensated metabolic alkalosis

A client diagnosed with gastric ulcers is admitted for a cauterization procedure. Which finding(s) should the nurse report to the healthcare provider? (Select all that apply.) A) Decreased level of consciousness. B) Hypoactive bowel sounds. C) Decreased urine output. D) Coffee-ground vomitus. E) Positive guaiac stools

A) Decreased level of consciousness. Correct C) Decreased urine output.

The nurse is analyzing an arterial blood gas (ABG) of a client who is mechanically ventilated. The ABG results are pH - 7.17; paCO2 - 70 mmHg; HCO3 - 30 mEq/liter. How should the nurse interpret this blood gas? A) Respiratory acidosis. B) Respiratory alkalosis. C) Metabolic acidosis. D) Metabolic alkalosis.

A) Respiratory Acidosis

client returns to the intensive care unit (ICU) after having a permanent pacemaker inserted. Which finding should the nurse observe for during the immediate hours after insertion? A) Beck's triad. B) Burns around the site C) Hypothermia D) Cardiac arrhythmia.

A) Beck's triad.

The nurse is preparing to suction an intubated client's endotracheal tube (ETT). Which action should the nurse do first prior to suctioning the client's ETT? A) Instill sterile normal saline into the ETT. B) Hyperoxygenate with 100% FiO 2 for 30 seconds. C) Increase the respiratory rate settings on the ventilator. D) Adjust the suction apparatus to low intermittent setting.

B) Hyperoxygenate with 100% FiO 2 for 30 seconds.

The nurse is caring for a client who is 4 days postoperative for abdominal surgery. The client reports acute onset of difficulty breathing. The nurse obtains the vital signs which include a heart rate of 120 beats/minute and respirations of 35 breaths/minute. Which diagnostic test should the nurse prepare the client to expect the healthcare provider to prescribe? A) D-dimer blood test. B) Coagulation time and platelet count. C) Echocardiogram. D) Mass spectrometry.

A) D-dimer blood test

The nurse is caring for a client who is demonstrating signs of impending death. The family is experiencing emotional distress as the client's condition declines. Which information should the nurse provide the family to facilitate the process? A) Encourage the family to give the client permission to die. B) Revoke the "do not resuscitate" advanced directive. C) Send the family to an area to seek spiritual comfort. D) Give the client pain medication during the end of life hours.

A) Encourage the family to give the client permission to die.

The nurse assists the healthcare provider with the insertion of a pulmonary artery (PA)catheter for a client presenting with cardiogenic shock. Which action is most important for the nurse to take to prevent life-threatening complications from pulmonary artery monitoring? A) Fast flush the PA distal port for no more than 2 seconds. B) void infusing blood products through the PA catheter. C) Clear pressure tubing of any blood after with-drawing a sample. D) Maintain 300 mmHg pressure around the bag attached to the tubing.

A) Fast flush the PA distal port for no more than 2 seconds

A client who has experienced trauma is admitted to the intensive care unit (ICU). The nurse's initial assessment findings include a Glasgow Coma Scale score of (3), pupils fixed and dilated with an absence of corneal reflex, blood pressure of 80/30 mmHg, core temperature of 95.7°F (35.4° C). The client's spouse asks the nurse when the client will wake up. How should the nurse respond? A) "Your spouse's condition indicates irreversible damage." B) "Let me contact the health care provider to answer your questions." C) "Each person is different and we need to wait and see what happens." D) "I need to initiate the volume expanders and warming blanket to stimulate a response."

B) let me contact the health care provider to answer your questions.

A client's cardiac rhythm reveals peaked "T" waves, a widening "QRS" complex and the flattening of "P" waves. Which medication should the nurse administer? A) Phosphate IV push. B) Furosemide IV push. C) Calcium gluconate IV push. D) Diluted potassium IV push.

C) Calcium gluconate IV push

The nurse is caring for a client in the intensive care unit who is receiving mechanical ventilation due to acute respiratory failure. The family asks when the client will be extubated. Which information should the nurse provide? A) When the client performs spontaneous breathing in between mechanical ventilation. B) Once all serum electrolyte and blood chemistry levels normalize. C) At the completion of intravenous antibiotic therapy and the infection is resolved. D) When the chest x-ray shows that the inflammation is resolved.

A) When the client performs spontaneous breathing in between mechanical ventilation.

A client with diabetic ketoacidosis is admitted to the intensive care unit and is manifesting respirations that are rapid and deep. Which descriptive term should the nurse use to document the client's breathing pattern? A) Kussmaul respirations. B) Cheyne stokes respirations. C) Apnea. D) Orthopnea.

A) Kussmaul respirations

A client who arrived in the emergency department is experiencing status epilepticus. Which medication should the nurse administer immediately? A) Lorazepam IV. B) Phenytoin PO. C) Morphine IV. D) Levetiracetim PO.

A) Lorazepam IV

A client with a demand pacemaker has a telemetry tracing with a pacing spike but no corresponding QRS complex. The client's myocardium is illiciting a QRS after a delay of several seconds. Which telemetry interpretation should the nurse conclude? A) Loss of capture. B) Ventricular fibrillation. C) Capture from an ectopic focus. D) A normal finding with a demand pacer

A) Loss of capture

A chest X-ray is prescribed for a client with possible adult respiratory distress syndrome (ARDS). Which radiographic finding represents the pathological processes of pulmonary edema and consolidation of the lungs as ARDS progresses ? A) White-out appearance. B) Infiltrates. C) Calcified cavities. D) Multiple nodules.

A) White-out appearance.

A male client who experienced a myocardial infarction (MI) asks the nurse what could have caused the MI, since he had been following a lifestyle of regular exercise and healthy food choices. Which response should the nurse provide to the client? A) A family history of heart disease is a risk factor for MI. B) Foods consumed when younger can cause plaque formation. C) Immediate medical treatment was a primary factor is survival. D) Myocardial tissue after a minor MI can heal with no long-term effects.

A) A family history of heart disease is a risk factor for MI.

A client is trying to talk with an endotracheal tube in place for mechanical ventilation. Which method is most readily available for the nurse to provide the client for communication? A) Communication board or paper pencil to write messages. B) Hand gestures that explain what the client wants to say. C) Communication by interrupting ventilator for short periods of time. D) Touch screen figures or text to voice communication computers.

A) Communication board or paper pencil to write messages

A client with chronic kidney disease (CKD) is admitted for strict fluid restriction. Which assessment finding requires additional nursing action? A) Crackles in the lungs. B) Decreased serum creatinine level. C) Increased weakness. D) Increase in serum potassium

A) Crackles in the lungs

A client is admitted to the intensive care unit with urosepsis. Which findings should the nurse report to the healthcare who suspects the client is at risk systemic inflammatory response syndrome (SIRS)? A) Temperature 102 F (38.9 C), PaCO 2 28, and apical pulse 100 beats per minute. B) Temperature 101 F (38.3 C), PaCO 2 55, apical pulse 80 beats per minute. C) Temperature 98.7 F (37.1 C), white blood cell count 5.5 cells/mm 3, respiratory rate 20 breaths per minute. D) Temperature 100.2 F (37.9 C), white blood cell count 10.0 cells/mm 3, respiratory rate 18 breaths per minute.

A)Temperature 102 F (38.9 C), PaCO 2 28, and apical pulse 100 beats per minute.

A client diagnosed with an end-stage terminal illness has decided to discontinue treatment. The client has become very detached and does not want to participate in the plan of care. Which action should the nurse implement first? A) Initiate a referral for a mental health consultation. B) Encourage the client to participate in their plan of care. C) Review the client's medical record for documented religious preference. D) Contact the hospital chaplain to provide spiritual counseling and guidance.

C) Review the clients medical record for documented religious preferences

Two days following cardiac bypass surgery, the nurse places a client's mediastinal chest tube to water seal. The client is using the incentive spirometer hourly while awake. Which assessment finding warrants intervention by the nurse? A) Serosanguineous fluid in collection container. B) Fluid fluctuation in tubing with respirations. C) Water seal level2 cm below the water seal fill line. D) Report of chest tube insertion site tenderness.

C) Water seal level2 cm below the water seal fill line.

A client reports shortness of breath and chest pressure radiating down the left arm. The client is receiving 2 liters of oxygen via nasal cannula and has two saline lock intravenous catheters. The nurse performs a 12 lead electrocardiogram (ECG) that shows ST segment elevation in leads II, III, aVF, and V4R. Which action should the nurse implement first? A) Give0.3 mg nitroglycerin sublingual. B) Administer4 mg IV morphine sulfate. C) Measure the ST segment height. D) Infuse 0.9% sodium chloride bolus.

D) Infuse 0.9% sodium chloride bolus

The nurse is caring for a client with severe sepsis related to a ruptured appendix.The clientis diaphoretic and reports lower extremity spasms. The nurse observes respirations that are uneven and labored. Arterial blood gas (ABG) results are pH 7.60, PaCO2 25 mmHg, HCO3 24 mEq/L, and PaO2 24 mmHg. Which assessment finding warrants immediate intervention by the nurse? A) Increased pulmonary secretions. B) Intercostal muscle retraction. C) Decreased breath sounds. D) Bronchovesicular breath sounds.

B) Intercostal muscle retraction.

The nurse is analyzing an arterial blood gas (ABG) of a client who has a nasogastric tube to low suction. The ABG results are pH - 7.48; paCO 2 - 50 mmHg; HCO 3 - 27mEq/liter. How should the nurse interpret this blood gas? A) Partially compensated respiratory acidosis. B) Partially compensated respiratory alkalosis. C) Partially compensated metabolic acidosis. D) Partially compensated metabolic alkalosis.

D) Partially compensated metabolic alkalosis.

The nurse is caring for a client admitted to the intensive care unit with a traumatic brain injury from a motor vehicle collision. The client is experiencing increased intracranial pressure (ICP). The healthcare provider explains to the family that the client needs to go to surgery for decompressive craniectomy. Which information should the nurse explain to the client? A) An over-lying cranial bone flap is removed to allow swelling brain tissue to expand. B) The procedure uses a magnetic resonce imaging-guided laser ablation. C) An opening into the skull is made to remove damage tissue. D) A burr hole is drilled through the cranial bones to evacuate blood.

A) An over-lying cranial bone flap is removed to allow swelling brain tissue to expand

The nurse is caring for a client who is recently extubated in the post anesthesia care unit (PACU). The client has humidified oxygen per mask and suddenly develops stridor and respiratory difficulty. Which action should the nurse implement? A) Call a rapid response team for emergency airway management. B) Encourage the client to take deep breaths, cough, and expectorate. C) Increase the flow rate of the humidified oxygen. D) Suction the client's mouth and oropharynx thoroughly.

A) Call a rapid response team for emergency airway management

The nurse is caring for a client who is receiving mechanical ventilation for acute respiratory distress syndrome (ARDS). The ventilator is alarming continuously indicating high peak pressures for the client. Which pathologic changes in the client is causing the ventilator alarms? A) Decreased lung compliance. B) Increased respiratory rate. C) Low volume of expired air. D) High tidal volumes.

A) Decreased lung compliance.

A client in the intensive care unit receives a STAT prescription for mannitol IV for cerebral edema post closed head injury. Which action should the nurse implement when preparing to administer the medication? A) Use a filtered needle to draw up the medication and an in-line filter during infusion. B) Place atropine at bedside for use if the client has bradycardia during administration. C) Hyperventilate the client prior to administration to decrease intracranial pressure. D) Stop all sedation while mannitol is being administered per secondary infusion.

A) Use a filtered needle to draw up the medication and an in-line filter during infusion.

A client reports to the nurse feeling achy and weak, being tired and coughing all the time, frequent headaches and experiencing night sweats. The client's assessment is significant for crackles scattered throughout the lungs, dependent peripheral edema +3/+4, S3 and S4 heart sounds, temperature of 102.4° F(39.1° C), heart rate of 110 beats/minute, respirations of 20 breaths/minute, and blood pressure of 105/60 mmHg with a mean arterial pressure of (75). Which diagnostic procedure should the nurse prepare to do first? A) Metabolic panel with electrolytes. B) Complete blood count. C) Liver function test. D) Blood culture.

D) Blood culture

The paramedics bring in a client who is a victim of a high speed motor vehicle collision. The client is semi-coherent, fading in and out of consciousness. Two large bore intravenous catheters have been put in place, and one is infusing with normal saline at 100 mL/hr. Which information is the most important for the triage nurse to obtain from the paramedics? A) The victim's vital signs upon arrival on the scene. B) Status of the other victims involved in the accident. C) Description of the motor vehicle collision circumstances. D) Police custody status of the victim pending further investigation

C) Description of the motor vehicle collision circumstances

The nurse receives report for a client with a history of heroin and alcohol abuse who has right arm cellulitis from a puncture wound. 0.9% sodium chloride is infusing at 50 mL/hr and oxygen at 2 liters per nasal canula. The client is flushed, diaphoretic, and slow to respond to verbal stimuli. Vital signs include oxygen saturation 94%, temperature 101° F (38.3° C), heart rate 124 beats/minute, respirations 26 breaths/minute, and blood pressure 88/24 mmHg. Which intervention should the nurse implement first? A) Administer antipyretic suppository. B) Obtain 2 sets of blood cultures. C) Increase IV fluids to 150 mL/min. D) Monitor client for withdrawal signs.

C) Increase IV fluids to 150 mL/min.

Two days after surgical repair of an aortic abdominal aneurysm (AAA), the cardiac monitor is displaying sinus bradycardia and blood pressure 82/40 mmHg. Nitroprusside is infusing at 10 mcg/kg/min and 0.9% sodium chloride at 100 mL/hr. Which intervention should the nurse implement first? A) Place the client's head flat and elevate the feet. B) Stop the nitroprusside infusion. C) Rapidly administer 1 liter intravenous fluids. D) Increase the 0.9% sodium chloride to 150 mL/hr.

Stop the nitroprusside infusion.

The nurse is caring for a client admitted to the critical care unit with multiple traumatic injuries sustained in a motor vehicle collision. The client has a Glasgow Coma Score of 6. Which intervention should the nurse prepare for the client? A) Intubation with mechanical ventilation. B) Nasogastric tube placement. C) Advanced cardiac life support. D) 12-lead electrocardiogram (ECG).

A) Intubation with mechanical ventilation

The nurse is caring for a client in the intensive care unit (ICU) with type 1 diabetes mellitus who has a blood glucose level of 600 mg/dL (33.3 mmol/L). Which clinical manifestation is most important for the nurse to report to the healthcare provider if the blood sugar continues to rise? A) Change in level of consciousness. B) Increase in urinary output. C) Onset of Kussmaul respirations. D) Decrease in serum potassium level.

A) Change in level of consciousness

The nurse is analyzing an arterial blood gas of a client who is mechanical ventilated. The ABG results are pH- 7.42; paCO 2- 50 mmHg; HCO 3- 30mEq/liter. How should the nurse interpret this blood gas? A) Fully compensated respiratory acidosis. B) Fully compensated respiratory alkalosis. C) Fully compensated metabolic acidosis. D) Fully compensated metabolic alkalosis.

A) Fully compensated respiratory acidosis

The nurse is caring for a client admitted to the surgical intensive care unit (SICU) on the first postoperative day after a kidney transplantation. Which intervention should the nurse include in the plan of care to prevent hypovolemia? A) Give IV fluids on a 1:1 ratio from output. B) Administer loop diuretics. C) Increase sodium intake. D) Provide sports drinks for hydration.

A) Give IV fluids on a 1:1 ratio from output.

The nurse is caring for a client in the critical care unit who is experiencing end-stage chronic obstructive pulmonary disease (COPD). The client is receiving oxygen at 40 L/minute via Vapotherm. The healthcare provider informs the client and family that there is no further treatment available for the COPD. Which intervention should the nurse recommend that is most beneficial to the client and family? A) Hospice services. B) Intubation with mechanical ventilation. C) Organ donation. D) Home health care.

A) Hospice services

The emergency department nurse is triaging a client whose spouse reports a sudden onset of symptoms to include fever, tremors, and decreased level of orientation and psychotic behavior, accompanied with the tachycardia and palpitations. The only significant medical history of the client is 4 days post-operative laparotomy appendectomy without complications and discharged to home 2 days ago. Which intervention should the nurse do first? A) Initiate a large bore intravenous catheter. B) Perform a twelve-lead electrocardiogram test. C) Insert an indwelling urinary catheter drainage system. D) Obtain serum electrolytes and kidney function test laboratory specimen

A) Initiate a large bore intravenous catheter.

The nurse is caring for a client who is diagnosed with diabetic ketoacidosis (DKA). The client reports abdominal pain and nausea, and presents with fruity-scented breath. The nurse performs a finger stick blood glucose with a reading too high to register. Which intervention is most important for the nurse to implement? A) Initiate a one liter bolus of 0.9% sodium chloride. B) Set up an IV pump to infuse IV insulin per protocol. C) Draw blood to evaluate a complete metabolic panel. D) Administer a prn IV dose of prescribed antiemetic.

A) Initiate a one liter bolus of 0.9% sodium chloride.

A client who returns to the postoperative unit after a total thyroidectomy suddenly becomes short of breath and develops stridor. What action should the nurse implement first? A) Call the rapid response team for emergency assistance. B) Encourage the client to relax as respiratory effort eases. C) Document the findings and monitor the client hourly. D) Call respiratory therapy to provide cool mist oxygen per mask.

A) Call the rapid response team for emergency assistance

A client diagnosed with heart failure has hemodynamic monitoring in place. Which actions should the nurse perform to obtain accurate readings from the hemodynamic monitor? (Select all that apply.) A) Measure the pressure readings in between the client's breaths. B) Place the transducer at the client's atria level and pulmonary artery level. C) Maintain a maximum pressure of 100 mmHg for the flush line continuously. D) Change out the intravenous solutions infusing via central lines every 12 hours. E) Calibrate the hemodynamic monitor by zeroing the transducer at the start of each shift.

A) Measure the pressure readings in between the client's breaths. Correct B) Place the transducer at the client's atria level and pulmonary artery level. E) Calibrate the hemodynamic monitor by zeroing the transducer at the start of each shift.

The nurse is caring for a client who underwent surgical repair of the aorta after sustaining injuries in a fall. Which finding indicates improved blood flow after the surgery? A) Movement of lower extremities. B) Decreased urinary output. C) Maintained weight. D) Blood pressure 90/50.

A) Movement of lower extremities

The nurse is caring for a client who is prescribed a potassium-sparing diuretic and has a potassium level of 6.1 mEq/L (6.1 mmol/L). Which intervention should the nurse perform? A) Obtain a 12-lead electrocardiogram (ECG). B) Call a rapid response. C) Insert an intravenous (IV) line. D) Schedule a cardiac catheterization.

A) Obtain a 12-lead electrocardiogram (ECG)

The nurse is caring for a client in the critical care unit who has type 2 diabetes mellitus and is admitted with hyperglycemic hyperosmolar syndrome (HHS). The health care provider prescribes an insulin drip of 0.1 unit/kg per hour based on a current blood glucose level of 670 mg/dL (35.3 mmol/L) . Which intervention should the nurse perform during this infusion? A) Obtain blood glucose levels hourly. B) Give potassium chloride 40 mEq per secondary infusion. C) Infuse Dextrose 5% with 0.45% NaCl (D 5 1/2 NS). D) Initiate a 2,000 calorie diabetic diet.

A) Obtain blood glucose levels hourly.

The health care provider has determined that a client has irreversible brain damage with subsequent brain death. Organ donation is discussed with the family. Which action should the nurse take prior to contacting the organ procurement organization (OPO)? A) Obtain informed consent. B) Disconnect the ventilator. C) Remove all jewelry. D) Contact the medical examiner.

A) Obtain informed consent

A client with syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is admitted to the intensive care unit with a serum sodium level of 112 mEq/L or mmol/L. Which protocol prescription should the nurse implement first? A) Obtain serum sodium levels every 4 hours. B) Provide oral sodium chloride supplements. C) Monitor fluid restriction and document hourly intake and output. D) Initiate normal saline IV at 100 mL/hour.

A) Obtain serum sodium levels every 4 hours

A client placed on hospice care is admitted for palliative radiation treatments to the neck. Which assessment should the nurse identify as a priority? A) Pain assessment. B) Respiratory assessment. C) Cardiovascular assessment. D) Integumentary assessment.

A) Pain assessment.

The nurse reports findings to the healthcare provider for a client who is admitted to the intensive care unit today with chronic obstructive pulmonary disease (COPD). When the nurse completes the report using the SBAR format, which statement best supports the nurse's reason for calling the healthcare provider? A) Prescription for an additional respiratory treatment. B) Admission today with difficulty breathing. C) History of COPD. D) Presence of expiratory wheezes in the lower lobes.

A) Prescription for an additional respiratory treatment

An older client is admitted to the intensive care unit after a small bowel resection. The postoperative prescriptions include a patient-controlled analgesia (PCA) device with morphine titrated per protocol. Which information should the nurse provide the client about the use of the PCA? A) Push button when pain is first experienced instead of waiting until pain is unbearable. B) Family members or visitors can press the button when the client grimaces in pain. C) Press the button every 15 minutes even when pain is not present. D) Delay pressing the button until the pain level is 8 on a scale of 1 to 10.

A) Push button when pain is first experienced instead of waiting until pain is unbareable

A client returns to the postoperative unit after arteriovenous graft placement. The telemetry is showing tall, peaked T waves on the waveform. Which action should the nurse implement? A) Review the client's recent serum potassium level. B) Prepare the client for synchronize cardioversion. C) Notify Rapid Response Team for ST-elevation myocardial infarction. D) Move the telemetry leads to the correct placement on the chest.

A) Review the client's recent serum potassium level.

The nurse is caring for a client in the critical care unit who has a pituitary tumor and subsequent diabetes insipidus (DI). Which finding indicates the need to place the client on seizure precautions? A) Sodium 155 mEq/L or mmol/L. B) Arterial pH 7.42. C) Calcium 9.5 mEq/L (4.75 mmol/L) D) Potassium 4.9 mEq/L or mmol/L.

A) Sodium 155 mEq/L or mmol/L.

A client who is hypotensive is receiving an infusion of dopamine 10 mcg/kg/minute IV through a peripheral line. The client begins to report burning at the IV site. Which action should the nurse implement? A) Stop the infusion and notify the healthcare provider of the findings. B) Check the line for blood return and irrigate the peripheral IV catheter. C) Apply a cold compress to the site and continue the infusion's rate. D) Slow the infusion rate and add a secondary IV of 0.9% sodium chloride.

A) Stop the infusion and notify the healthcare provider of the findings.

Which intervention should the nurse perform prior to the removal of an endotracheal tube from a client? A) Suction the endotracheal tube thoroughly. B) Pre-medicate the client with pain medication. C) Increase the FiO 2 for a minimum of 15 minutes. D) Provide positive pressure ventilation prior to extubation.

A) Suction the endotracheal tube thoroughly

The nurse is collecting a sample for arterial blood gases (ABGs) for a client with hypoxia due to cardiomyopathy. Which should the nurse assess prior to obtaining the arterial blood sample? A) Ulnar blood flow. B) Apical heart rate. C) Oxygenation level. D) Breath sounds.

A) Ulnar blood flow

The nurse is preparing a client with acute kidney injury (AKI) f or hemodialysis in the intensive care unit (ICU). Which assessment should the nurse obtain prior to beginning the procedure? A) Weight using the ICU bed scales. B) Arteriovenous (AV) fistula site. C) Capillary refill. D) Urine color and clarity.

A) Weight using the ICU bed scales.

The cardiac monitor alarms and the nurse finds a client with no palpable carotid pulse and no spontaneous respirations. The cardiac monitor displays a normal sinus rhythm. Which intervention should the nurse implement? A) Assess for signs of cardiac tamponade. B) Begin chest compressions at 120 per minute. C) Check for responsiveness with sternal rub. D) Obtain a STAT 12 lead electrocardiogram.

B) Begin chest compressions at 120 per minute

According to the paramedic's report, the victim of a motor vehicle collision was sitting in the passenger seat on the left side of the vehicle. The vehicle was stopped at a traffic light when the vehicle was hit on the left side by another vehicle traveling at speeds exceeding 60 mph (97 kmh). The client reports slight tenderness and achiness on (L) side of thorax and body. The significant assessment findings include: weak and thready pulse; diffuse abdominal pain, tenderness and guarding present upon palpation; skin is diaphoretic and extremities cool to touch, capillary refill +4 in extremities, and bruising is present in the (L) flank area and progresses towards the abdomen. Vital signs are temperature- 97.2° F (36.2° C), pulse- 110 beats/minute, respirations- 22 breaths/minute, blood pressure 84/46 mmHg, MAP- (57), and pulse oximetry 90% on 2 lpm O2 via nasal cannula.Which potential injuries should the triage nurse assess? (Select all that apply.) A) Flailed ribs. B) Fractured liver. C) Ruptured spleen. D) Cardiac tamponade. E) Tension pneumothorax

B) Fractured liver C) Ruptured spleen

A client falls off a ladder approximately 15 feet high and is admitted to the ICU for observation due to a small intracranial bleed noted in the left occipital area of the brain as observed on the CT Scan done in the emergency department. The client has been stable for the past 12 hours. The client reports to the nurse a new onset of pain in the left shoulder. Which action should the nurse do next? A) Contact the healthcare provider. B) Perform an abdominal assessment. C) Observe the client's pupillary response. D) Examine the left shoulder's range of motion.

B) Perform an abdominal assessment

A client who is critically ill requests to receive the Sacrament of the Anointing of the Sick. Which clergy member should the nurse contact? A) Rabbi. B) Priest. C) Sharma. D) Ayatollah.

B) Priest

The nurse is analyzing an arterial blood gas (ABG) of a client who is mechanically ventilated. The ABG results are pH- 7.52; paCO2- 30 mmHg; HCO3- 28 mEq/liter. How should the nurse interpret this blood gas? A) Respiratory acidosis. B) Respiratory alkalosis. C) Metabolic acidosis. D) Metabolic alkalosis.

B) Respiratory alkalosis

A client's blood pressure drops suddenly from 160/90 mmHg to 60/40 mmHg minutes after the nurse administers a 0.3 mg sublingual dose of nitroglycerin when the client reports crushing chest pain. The client is experiencing severe nausea, dizziness, and left arm numbness. Which intervention should the nurse implement? A) Give a PRN antiemetic medication. B) Administer second dose of nitroglycerin. C) Infuse a rapid0.9% normal saline bolus. D) Apply external pace maker pads to chest.

C) Infuse a rapid0.9% normal saline bolus.