Comp-lex

A nurse is preparing to administer heparin sodium 800 units per hour by continuous intravenous infusion. The pharmacy prepares the medication and delivers the solution labeled heparin sodium 20,000 units per 250 mL in D5W. At what rate will the nurse set the infusion ml/hr ? - 10mL/hr

- 10mL/hr

A nurse is caring for a client with a permanent pacemaker. Click on the letter that represents the client's atrial pacer spike. -Click on A

-Click on A

Review the electronic health record. For each finding at 0400, indicate whether the implemented interventions by the nurse were: Effective, Ineffective, or Unrelated. -Effective: Heart rate, BP, The client states. Reports no shortness of breath -Uneffective: 2+ pitting edema legs and sacrum -Unrelated: Hypoactive bowel sounds

-Effective: Heart rate, BP, The client states. Reports no shortness of breath -Uneffective: 2+ pitting edema legs and sacrum -Unrelated: Hypoactive bowel sounds

Review the electronic health record. For each potential nursing intervention, click to specify whether the intervention is indicated or contraindicated for the care of the client. Request an order to change the oxygen delivery device: Prepare the client for defibrillation: Provide oral suctioning as needed : Place the client in the tripod position: Request an order to administer an intravenous fluid bolus: Request an order to administer piperacillin intravenously : Assist the client to perform pursed lip breathing: Request an order for arterial blood gases:

-Request an order to change the oxygen delivery device: Indicated -Prepare the client for defibrillation: Contraindicated -Provide oral suctioning as needed : Indicated -Place the client in the tripod position: Indicated -Request an order to administer an intravenous fluid bolus: Indicated -Request an order to administer piperacillin intravenously : Indicated -Assist the client to perform pursed lip breathing: Indicated -Request an order for arterial blood gases: Indicated

A nurse is preparing to administer morphine 6 mg via IV bolus to a client. The amount available is morphine 8 mg/mL. How many mL should the nurse administer per dose?

0.75mL

The nurse is caring for a client when the monitor alarms with the heart rhythm shown below. Place the nursing actions in priority order. 1. Assess for responsiveness 2. Call a code blue 3. Check the client's carotid pulse 4. Begin chest compressions 5. Provide 2 breaths per 30 compressions

1. Assess for responsiveness 2. Call a code blue 3. Check the client's carotid pulse 4. Begin chest compressions 5. Provide 2 breaths per 30 compressions

A client arrives at the emergency department with stridor and hoarseness. Which priority action should the nurse anticipate at this time? A Prepare for endotracheal intubation B Prepare for chest needle decompression C Insert two large bore intravenous catheters (IVs) D Administer prescribed pain medication

A Prepare for endotracheal intubation

The nurse is caring for a client with hemopneumothorax that is being treated with a chest tube. Which observation should the nurse immediately report to the healthcare provider? A. 600 mL of blood in the collection chamber in the last two hours B. Continuous bubbling in the suction-control chamber C. Small amount of subcutaneous emphysema at the insertion site D. Intermittent bubbling in the water seal chamber

A. 600 mL of blood in the collection chamber in the last two hours

The nurse is caring for several clients at risk for hypercapnic respiratory failure. After the bedside shift report on the clients, which client should the nurse see first? A. A client with chronic obstructive pulmonary disease (COD) who has intercostal retractions B. A client who underwent abdominal surgery and is currently using an incentive spirometer C. A client with pneumonia who is receiving oxygen therapy via nasal cannula D. A client with a history of asthma who has mild shortness of breath

A. A client with chronic obstructive pulmonary disease (COD) who has intercostal retractions

A nurse enters a client's room and finds the client unresponsive and without a pulse. The client's family member was considering changing the client's status to a do-not-resuscitate (DNR), but the request has not been made, and the healthcare provider has not provided an order for a DNR. What action should the nurse take first? A. Activate the emergency response "code blue" team B. Call the healthcare provider and ask for a DNR order C. Call the client's family member and ask about the request D. Seek immediate help from the charge nurse

A. Activate the emergency response "code blue" team

The nurse is caring for a client in ventricular tachycardia (VT) with a pulse. The interdisciplinary team is preparing the client for synchronized cardioversion. After administering fentanyl, which action should the nurse take next? A. Administer midazolam for sedation B. Have the client hold their breath and bear down C. Administer intravenous epinephrine D. Prepare to assist with intubation

A. Administer midazolam for sedation

A nurse is caring for a client who reports incisional pain when deep breathing after a coronary artery bypass graft (CABG). Which action should the nurse take next? A. Administer the client's pain medication as prescribed. B. Allow the client to rest before doing deep breathing exercises. C. Obtain a stat 12-lead electrocardiogram (EKG). D. Request the respiratory therapist to instruct the client on deep breathing techniques.

A. Administer the client's pain medication as prescribed.

Review the electronic health record. Which 2 healthcare provider orders should the nurse implement first? Select two orders. A. Arterial blood gas (ABG) B. Sputum culture and sensitivity (C&S) C. Azithromycin 500 mg IV every 24 hours D. Comprehensive metabolic panel (CMP) E. Albuterol nebulized every 2 hours PRN for increased difficulty breathing F. Insert an indwelling urethral catheter

A. Arterial blood gas (ABG) E. Albuterol nebulized every 2 hours PR

The nurse is caring for a client diagnosed with ST-segment elevation myocardial infarction (STEMI). The healthcare provider tells the nurse to prepare the client for percutaneous coronary intervention (PCI). Which action should the nurse take next? A. Ask the client about iodine or shellfish allergies B. Prepare to administer alteplase at the bedside C. Place the client on oxygen using a face mask D. Explain the procedure to the client

A. Ask the client about iodine or shellfish allergies

The nurse is caring for a client who is intubated and mechanically ventilated. The client is restless and coughing, and the client's heart rate has increased. Which action should the nurse take? A. Assess the need for suctioning B. Check the end-tidal CO2 monitor C. Tell the client to relax and stay calm D. Check the client's temperature

A. Assess the need for suctioning

A nurse is planning care for a terminally ill client on hospice care. Which actions should the nurse plan to implement? Select all that apply. A. Assist the client with relaxation exercises and guided imagery. B. Encourage family to spend time with the client. C. Administer prescribed pain medications. D. Assess the client's spiritual needs. E. Perform complete head-to-toe assessments every four hours.

A. Assist the client with relaxation exercises and guided imagery. B. Encourage family to spend time with the client. C. Administer prescribed pain medications. D. Assess the client's spiritual needs.

A nurse is caring for a client immediately following a cardiac catheterization with a femoral puncture. Which nursing action(s) should be included in the client's plan of care? Select all that apply. A. Check peripheral pulses in the affected extremity B. Keep the client's hip and leg straight C. Have the client ambulate D. Measure the client's vital signs every 4 hour E. Monitor the client's urine output

A. Check peripheral pulses in the affected extremity B. Keep the client's hip and leg straight E. Monitor the client's urine output

The nurse is caring for a client who is intubated and mechanically ventilated. When planning care, what should the nurse have available in the client's room? Select all that apply. A. Communication board B. Suction equipment C. Venturi mask D. bag-valve-mask resuscitator E. Chlorhexidine oral care supplies

A. Communication board B. Suction equipment D. bag-valve-mask resuscitator E. Chlorhexidine oral care supplies

A nurse manager of the intensive care unit recognizes the nurses on the unit are experiencing moral distress.Which actions should the nurse manager take to best respond to the moral distress of the nurses? Drag and drop the appropriate responses to the box on the right. Appropriate Responses A. Create a private space for staff to sit uninterrupted to relax. B. Schedule a debriefing session to provide closure and assess for follow-up. C. Set up meetings with the nurses to discuss the situation.

A. Create a private space for staff to sit uninterrupted to relax. B. Schedule a debriefing session to provide closure and assess for follow-up. C. Set up meetings with the nurses to discuss the situation

A nurse is planning education for a client with a new nitroglycerin prescription who is being discharged after a myocardial infarction and is concerned about resuming sexual activity. Which information should the nurse plan to provide? Select all that apply. A. Erectile dysfunction medications should not be taken when taking nitroglycerin. B. Avoid intensely hot or extremely cold showers after intercourse. C. Sex is a physical activity that should be resumed slowly after having a heart attack. D. Increase food and caloric intake prior to engaging in sexual activity. E. It is generally safe to resume sexual activity three to five days after discharge.

A. Erectile dysfunction medications should not be taken when taking nitroglycerin. B. Avoid intensely hot or extremely cold showers after intercourse C. Sex is a physical activity that should be resumed slowly after having a heart attack.

A nurse is caring for a postoperative client. The client has a pleural chest tube connected to suction and a water-seal drainage system. Which should indicate to the nurse that the chest tube is functioning properly? A. Fluctuation of the fluid level within the water seal chamber B. Equal amounts of fluid drainage in each collection chamber C. Absence of fluid in the drainage tubing D. Continuous bubbling within the water seal chamber

A. Fluctuation of the fluid level within the water seal chamber

A nurse is educating a client following the insertion of a permanent pacemaker. Which information should be included in the educational plan? Select all that apply. A. Handheld metal detectors should not be placed directly over the pacemaker. B. Resume activities that can cause jolting, such as horseback riding, after 4 weeks. C. Do not drive until cleared by the healthcare provider. D. Do not have a microwave oven in the home. E. Count your pulse for 1 minute each morning.

A. Handheld metal detectors should not be placed directly over the pacemaker. B. Resume activities that can cause jolting, such as horseback riding, after 4 weeks. C. Do not drive until cleared by the healthcare provider.

A nurse is caring for a client who was recently intubated and placed on mechanical ventilation. Which action (s) should the nurse include in the client's plan of care? Select all the apply. A Implement the ventilator acquired pneumonia (VAP) bundle B Suction the endotracheal tube every hour. C Assess the face for skin breakdown around the tube. D Document the correct position of the endotracheal tube. E Administer prescribed pain medication as needed.

A. Implement the ventilator acquired pneumonia (VAP) bundle C. Assess the face for skin breakdown around the tube. D. Document the correct position of the endotracheal tube. E. Administer prescribed pain medication as needed.

A nurse is caring for a client receiving hospice care for an inoperable brain tumor. When completing an assessment at the end of life, which finding should the nurse expect? A. Muscle flaccidity B. Bowel control C. Increased thirst sensation D. Awareness of surroundings

A. Muscle flaccidity

A client with coronary artery disease presents to the emergency department with a new onset of chest discomfort. What action(s) should the nurse anticipate including in the plan of care? Select all that apply. A. Obtaining a 12-lead EKG B. Encouraging the client to cough and deep breathe C. Monitoring continuous pulse oximetry D. Administering nitroglycerin sublingually E. Administering morphine IV push

A. Obtaining a 12-lead EKG C. Monitoring continuous pulse oximetry D. Administering nitroglycerin sublingually E. Administering morphine IV push

A nurse is caring for a client who reports sudden, severe chest pain. What should the nurse do to determine if the client is experiencing a myocardial infarction? A. Perform a 12-lead electrocardiogram (ECG) B. Assess the client's heart and lung sounds C. Request an order for cardiac enzyme studies D. Ask if the pain is is midsternal and severe

A. Perform a 12-lead electrocardiogram (ECG)

A nurse is caring for a client recovering from surgery three days ago. Upon assessment, the nurse observes that the client is confused, agitated, trying to climb out of bed, and reports seeing non-existent people in the room. Which complication should the nurse suspect the client is experiencing? A Postoperative delirium B Senile dementia C Polypharmacy D Postoperative infection

A. Postoperative delirium

A nurse is caring for a client with acute respiratory failure. Which finding(s) should the nurse anticipate? Select all that apply. A Severe dyspnea B Hypertension ?? C Decreased level of consciousness D Nausea E Agitation

A. Severe dyspnea B. Hypertension ?? C. Decreased level of consciousness D. Nausea E. Agitation

The nurse informs a client that the primary healthcare provider will be arriving at the hospital soon to remove the client's chest tube. In describing the tube removal procedure, which action should the nurse instruct the client to take at the moment the tube is removed? A. Take a deep breath and bear down during tube removal. B. Breathe normally during tube removal. C. Inhale and exhale quickly while the tube is removed. D. Hyperventilate during the removal of the tube.

A. Take a deep breath and bear down during tube removal.

The nurse is assigned to a client with Acute Respiratory Distress Syndrome (ARDS) who is on a ventilator. Which finding indicates that the client's condition is worsening? A. There are no breath sounds in the left lung and expiratory crackles in the right lung. B. The blood work shows a pH of 7.36 and PaCO2 of 38 C. There is the beginning of a pressure ulcer on the side of the client's mouth. D. The high pressure ventilator alarm goes off every few minutes

A. There are no breath sounds in the left lung and expiratory crackles in the right lung.

A nurse is providing education to a client about palliative care. Which statement by the client indicates a need for further teaching? A "Palliative care will provide me with symptom relief and comfort. B "Palliative care means I will not make it more than 6 more months." C "While on palliative care, I will still be able to perform activities I enjoy." D "While on palliative care, my family will also receive support from the team."

B "Palliative care means I will not make it more than 6 more months."

A nurse is caring for a client with the following assessment findings (see exhibit below). What action should the nurse take first? Heart rate 125, RR 29, BP 90/65, Sa02 88% on Non-Rebreather Mask Neuro: Oriented to self only A 500 mL NS fluid bolus B Rapid sequence intubation C Continuous renal replacement D Central line placemen

B Rapid sequence intubation

A nurse is caring for a client who has been declared brain-dead. The client's family has questions about organ donation. Which response by the nursing transplant coordinator is best? A. "Thinking about what your spouse would have wanted in this situation may be helpful."?? B. "Organ donation can help save lives, and that is something to be thankful about."?? C. "I think you will feel better about the situation if you donate your spouse's organs." D. "Maybe you should speak with your religious leader to find out what they think about a donation.

B. "Organ donation can help save lives, and that is something to be thankful about."

A nurse is monitoring a client on a cardiac unit. The nurse should assess the client's electrocardiogram (ECG) strip as representing which cardiac dysrhythmia? A. 2nd degree heart block, Mobitz, type II B. Atrial fibrillation C. 2nd degree heart block, Mobitz, type I D. Complete heart block

B. Atrial fibrillation

A client is receiving a continuous infusion of dexedetomidine at 0.6mcq/kg/hr for severe agitation. The nurse would anticipate decreasing the infusion rate for which clinical manifestation (s)? Select all that apply. A Triglyceride level 302 mg/dL B Blood pressure 86/48 mmHg C Heart rate 102 beats per minute D Blood pressure 142/78 mmHg E Heart rate 54 beats per minute

B. Blood pressure 86/48 mmHg E. Heart rate 54 beats per minute

Which action should the nurse perform prior to defibrillating a client? A Ensure the defibrillator is in synchronous mode B Confirm that everyone is clear of contact with the client and bed C Administer a sedative before giving the shock D Stop compressions (CPR when pads are being placed on client's chest)

B. Confirm that everyone is clear of contact with the client and bed

A nurse in an emergency department is assessing a new client. Which finding is the priority for the nurse to address? A. Blood pressure of 104/63 mmH B. Cyanosis to the skin and mucous membranes C. Generalized diaphoresis D. Client rates pain 9 out of 10 on a 0-10 scale

B. Cyanosis to the skin and mucous membranes

The nurse admits a terminally ill client to the hospital. What is the first action that the nurse should plan to complete? A. Discuss the normal grief process with the client and family. B. Determine the client's wishes about end-of-life care. C. Obtain a consult for palliative end-of-life care. D. Emphasize the importance of addressing any family concerns.

B. Determine the client's wishes about end-of-life care.

A nurse is caring for a client immediately after a permanent pacemaker insertion. The client's cardiac monitor shows pacemaker spikes with no complexes following the spikes. Which action should the nurse perform next? A. Call the healthcare provider immediately B. Feel for the presence of a palpable pulse C. Have the client move onto their right side D. Prepare the client for defibrillation

B. Feel for the presence of a palpable pulse

A nurse is caring for a client who is on mechanical ventilation. The client's oxygen saturation has dropped to 85% and the provider is notified. Which action by the interdisciplinary team will best improve the client's oxygenation? A Administering a bronchodilator medication B Increasing the FiO2 setting on the ventilator C Placing the client in Trendelenburg's position D Suctioning the client's endotracheal tube

B. Increasing the FiO2 setting on the ventilator

Immediately after extubation, the nursing assessment reveals the adult client is coughing and emitting a high-pitched noise when inhaling. What is the priority nursing action? A. Reassure the client that these symptoms are common and will subside B. Monitor airway and inform the client that reintubation may be necessary C. Instruct the client to limit speaking to decrease vocal cord irritation D. Encourage the client to cough and deep breathe every two hours

B. Monitor airway and inform the client that reintubation may be necessary

A nurse is caring for a client that reports pain in the jaw, back, and shoulder. The client also reports shortness of breath and nausea. Which action should the nurse take first? A. Administer an enteric-coated aspirin. B. Obtain an electrocardiogram (ECG). C. Administer morphine. D. Reduce environmental stimulation.

B. Obtain an electrocardiogram (ECG)

A nurse is caring for a client admitted with acute myocardial infarction (AMI). Three days later, the nurse is concerned that the client may have developed heart failure. Which assessment finding best supports the nurse's concern? A. Decreased urine output B. ST elevation on the EKG C. Rub heard on auscultation D. Narrow pulse pressure

B. ST elevation on the EKG

A nurse is assisting in the removal of a chest tube from a postoperative client. Which rationale best explains the need for covering the insertion site with an occlusive dressing? A. To prevent infection at the insertion site B. To prevent air from entering the chest wall C. To prevent increased negative intrathoracic pressure D. To prevent drainage from causing skin breakdown

B. To prevent air from entering the chest wall Rationale: If enough fluid or air accumulates in the pleural space, the normally negative subatmospheric pressure becomes positive and the lungs collapse

A charge nurse is helping nurses on the unit with their clients. For which clients should the rapid response team be activated? Select all that apply. A. A client admitted to the intensive care unit with coffee-ground emesis B. A client who is post-operative complaining of pain rated 8/10. C. A client admitted with appendicitis who is unarousable with a blood pressure of 74/44 mm Hg. D. A client receiving a heparin infusion who becomes lethargic and is bleeding from IV sites. E. A client with terminal cancer and a do-not-resuscitate (DR) order who stops breathing.

C. A client admitted with appendicitis who is unarousable with a blood pressure of 74/44 mm Hg. D. A client receiving a heparin infusion who becomes lethargic and is bleeding from IV sites

A nurse is caring for a client following a near-drowning incident about 3 hours ago who reports headache, fatigue, and shortness of breath. The client is restless, tachycardic, and hypertensive. For which problem is the nurse most concerned? A. Pneumonia B .Pneumoconiosis C. Acute respiratory failure D. Pleural effusion

C. Acute respiratory failure

A nurse is caring for a client with an endotracheal tube. The client is receiving mechanical ventilation and pulls out the endotracheal tube. Which action should the nurse take first? A. Prepare the client for reintubation. B. Elevate the head of the client's bed. C. Assess the client's airway. D. Suction the client's mouth

C. Assess the client's airway.

A nurse is planning to implement prone positioning as prescribed for a client with adult respiratory distress syndrome (ARDS). Which action should the nurse plan to take? A. Contact the provider for extubation before prone positioning. B. Keep the client in the prone position for at least 20 hours daily. C. Ensure at least three colleagues are available to assist with positioning. D. Initiate the client's gastric tube feeding immediately before repositioning.

C. Ensure at least three colleagues are available to assist with positioning.

A nurse is caring for a client on mechanical ventilation. The client becomes agitated when trying to communicate their needs. What action should the nurse take? A. Ask the family to leave the room to allow the client to rest. B. Increase the client's level of sedation. C. Provide a white board so the client can write their request. D. Assess the client's RASS score and increase the sedation as prescribed.

C. Provide a white board so the client can write their request.

A nurse is planning care for a client in the intensive care unit (ICU) with acute respiratory failure who is intubated. Which action(s) should the nurse include in the plan of care? Select all that apply. A. Checking neurological status once a shift B. Extubating the client within 24 hours C. Providing emotional support to families D. Monitoring respiratory rate and pattern E. Maintaining a patent airway

C. Providing emotional support to families D. Monitoring respiratory rate and pattern E. Maintaining a patent airway

When admitting a client with possible respiratory failure and a high PaCO2, which assessment information should be immediately reported to the healthcare provider? A. The client's blood pressure is 164/98. B. The client's oxygen saturation is 90%. C. The client appears somnolent. D. The client reports fatigue.

C. The client appears somnolent.

A nurse is caring for a client in the intensive care unit and includes the ABCDEF bundle in the client's plan of care. What is the purpose of this bundle? A. This bundle ensures adequate nutrition for the client within an intensive care unit B .This bundle includes the nurse consulting the wound/ostomy nurse when needed C. This bundle sets standards for the management of clients within complex health issues D. This bundle assesses the oxygenation status of the client on mechanical ventilation

C. This bundle sets standards for the management of clients within complex health issues

The nurse is caring for a client who has just arrived from the medical unit after a rapid response. The client was diagnosed with septic shock and intubated. Which action should the nurse take when the client's family members arrive? A. Ask them to please wait until visiting hours start B. Let them know that pastoral support is available C. prepare them by briefly explaining what to expect D. Take the family to the client's room immediately

C. prepare them by briefly explaining what to expect

A nurse provided education for a client with end-stage cancer transitioning to palliative care. Which statement made by the client indicates the need for further education? A. "It is comforting to know that my spouse will be emotionally supported after I am gone." B. "I am relieved that if I need more pain medication, I will receive it." C. "I am glad my family can stay with me as much as possible." D .The new treatments for my cancer will be available soon so I can stop palliative care."

D .The new treatments for my cancer will be available soon so I can stop palliative care."

Review the electronic health record. Select the client findings that require immediate follow-up by the nurse. Select all that apply. A Current smoking status B Clubbing presence C Lung sounds D Cough with green sputum E Client orientation

D Cough with green sputum E Client orientation

The nurse is assessing a client with decreased cardiac output. Which findings require immediate intervention? A. Weight gain of 2 pounds in three days, blood pressure of 130/80 mmg, and mild dyspnea with exercise B. Sp02 of 92% on 2 liters of oxygen, respirations of 20 breaths per minute, and 1+ edema of lower extremities C. Blood pressure of 110/62 mmH, atrial fibrillation with a heart rate of 74 beats per minute, and crackles in bilateral lungs D. Confusion, urine output of 15 mL over the last two hours, and orthopnea

D. Confusion, urine output of 15 mL over the last two hours, and orthopnea

A nurse in an emergency department is caring for a client with chest pressure, dyspnea, and left jaw pain. Vital signs include: temperature 99.9° F, blood pressure 152/88 mm Hg, heart rate 122 beats per minute, respiration rate 25 breaths per minute, and Sp02 of 89%. Which action should be performed first? A. Administer prescribed aspirin. B. Insert an intravenous (IV) catheter. C. Obtain a blood sample for troponin D. Initiate oxygen therapy.

D. Initiate oxygen therapy.

The nurse is assessing a client with a low-pressure ventilator alarm. The nurse is unable to find the cause of the alarm. What is the nurse's priority action? A .Continue to troubleshoot the alarm B. Suction the endotracheal tube using saline C. Call the rapid response team D. Manually ventilate the client

D. Manually ventilate the client

A nurse is caring for a critically ill client who has been intubated and placed on a mechanical ventilator. The client's family wishes that the client not be resuscitated if conditions worsen. The client has not yet been able to make their wishes known as they have not been awake and there are no advanced directives. Which action by the nurse is most appropriate? A. Wait until the client is able to make their wishes known before making any decisions and support the family. B. Explain to the family that it is up to the healthcare provider and team whether to perform or withhold resuscitation efforts. C. Follow the family's wishes and withhold resuscitation efforts if the client's condition worsens. D. Notify the healthcare provider that the family would like to request a do-not-resuscitate (DR) status for the client.

D. Notify the healthcare provider that the family would like to request a do-not-resuscitate (DR) status for the client.

A nurse is assessing a client's arterial blood gas results. What finding is expected with hyperventilation? A.Pa02 of 89 B. pH of 7.40 C. PaHCO3 of 24 D. PaCO2 of 32

D. PaCO2 of 32

A nurse is giving a change-of-shift report using ISBAR to the oncoming nurse about a client with a traumatic brain injury. Which information should the nurse include in the background segment of ISBAR? A. Intracranial pressure readings B. Plan of care changes for upcoming shift C. Glasgow results D. Pertinent medical history

D. Pertinent medical history

A nurse is caring for a client who has an electrocardiogram (ECG) showing complete heart block. Which action should the nurse take? A. Request a prescription for intravenous atropine B. Massage the client's carotid arteries one at a time C. Have the client hold their breath and bear down D. Prepare the client for transcutaneous pacing

D. Prepare the client for transcutaneous pacing

The nurse responds to a ventilator alarm to find the client now completely extubated. The client's heart rate is 116 beats per minute, and oxygen saturation is 90%. Which action should the nurse take next? A. Explain to the client what has happened and provide support B. Place the client in high fowlers and suction the clients mouth C. Leave the room and call out for immediate assistance D. Provide supplemental oxygen with the bag-valve-mask (BVM)

D. Provide supplemental oxygen with the bag-valve-mask (BVM)

The nurse is caring for a client who has a pneumothorax and is having a chest tube inserted. What action should the nurse take immediately after the chest tube has been inserted? A. Check the client's temperature and urine output B. Check the client's breathing and lung sounds C. Ensure there is a wall suction set up available D. Request a portable chest X-ray to check the tube

D. Request a portable chest X-ray to check the tube

A client who is intubated and receiving mechanical ventilation is anxious, restless, and grimacing. Which action should the nurse take first? A. Increase the rate for the ordered propofol infusion B. Sedate the client with the ordered midazolam IV push C. Manually ventilate the client with a bag-valve-mask device D. Try to identify the cause of the distress and provide reassurance

D. Try to identify the cause of the distress and provide reassurance

The nurse is caring for several clients. Which client should the nurse recognize may require intubation and mechanical ventilation? A. A client who has a concussion and is mildly disoriented B. A client who has pneumonia and a productive cough C. A client who has angioedema related to an allergic reaction D. a client who has chronic obstructive pulmonary disease and an elevated PCO2

D. a client who has chronic obstructive pulmonary disease and an elevated PCO2

Review the electronic health record. For each assessment finding below, click to specify if the finding is consistent with the disease process of pneumonia or COPD exacerbation. Diminished lung sounds bilaterally Labored breathing Temperature 101.1° F (38.4° C) Sp02 64% on 15 L/min via non-rebreather Heart rate 124 beats per minute Respirations 32 breaths per minute Green thick sputum

Diminished lung sounds bilaterally - COPD Labored breathing - Pneumonia, COPD Temperature 101.1° F (38.4° C) - Pneumonia Sp02 64% on 15 L/min via non-rebreather - Pneumonia, COPD Heart rate 124 beats per minute - Pneumonia, COPD Respirations 32 breaths per minute - Pneumonia, COPD Green thick sputum - Pneumonia

A client with a history of coronary artery disease is admitted to the hospital with dyspnea, shortness of breath, and chest pain rated 8/10 on a 1-10 pain scale. The client's skin is warm and dry. The nurse obtains vital signs, which are as follows: temperature 99.8F (36.7C), blood pressure 178/89 mmHg, heart rate 119 beats per minute respirations 30 breaths per minute, and pulse oximetry 86% on room air. The nurse begins treatment with 4 liter of oxygen via nasal cannula, morphine, nitroglycerine, and aspirin. Improving - Respirations, Pulse Ox, Blood pressure Declining - Skin Unchanged - Chest pain 8/10 on a 1-10 pain scale

Improving - Respirations, Pulse Ox, Blood pressure Declining - Skin Unchanged - Chest pain 8/10 on a 1-10 pain scale

The nurse is caring for a client who suddenly slumps over and stops breathing. The telemetry monitor shows the following (see exhibit). The client does not have a pulse. Drag the actions the nurse should take to the box on the right. Prepare for synchronized cardioversion Begin cardiopulmonary resuscitation Activate a code response Prepare for defibrillation Lie the client flat on their back

Prepare for synchronized cardioversion Begin cardiopulmonary resuscitation Activate a code response Prepare for defibrillation Lie the client flat on their back

Review the electronic health record. Complete the following sentence by choosing from the list of options. The client is at highest risk for developing 1. Respiratory Acidosis

Respiratory Acidosis

Review the electronic health record. For each potential prescription, indicate if the prescription is anticipated or not anticipated The client presents to the emergency department complaining of a poor appetite, swelling in the ankles and feet, nocturnal diuresis, chest heaviness, and sharp pain in the chest on and off for two days. The client has a history of coronary artery disease. Chest pain and heaviness seem unrelated to activity and have become more frequent. Serial cardiac troponins Chaplain consult Carotid ultrasound Obtain blood cultures 12-lead electrocardiogram (ECG) - Chest x-ray Oxygen titrated to greater than 94%

Serial cardiac troponins - Anticipated Chaplain consult - Unanticipated Carotid ultrasound - Unanticipated Obtain blood cultures - Anticipated 12-lead electrocardiogram (ECG) - Anticipated Chest x-ray - Anticipated Oxygen titrated to greater than 94% - Anticipated