The nurse notes that a patient’s endotracheal tube (ET), which was at the 21-cm mark, is now at the 24-cm mark and the patient appears anxious and restless. Which action should the nurse take first?

A male client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in right upper lobe of the lung. The nurse immediately assesses for other signs of which of the following:

The low-exhaled volume alarm sounds on a mechanical ventilator of a client with an endotracheal tube. The nurse determines that the cause for alarm activation may be which complication?

The MD provide the Following Order 18Units/kg/Hr of Heparin IV. Based on the bag from Pharmacy below and the patient weighing 215lbs, how would you set up the pump correctly (ml/hr). Only put numbers in the answer blank not ml/hr. Round to the nearest tenth.  

The nurse cares for a 78-year-old female admitted to the medical intensive care unit in respiratory distress. Nurses’ Notes   0900. Client was admitted to the ICU in respiratory distress after minimal response to high flow oxygen for a pulse oximeter reading of 83% in room air. Crackles heard bilaterally in lower lobes with diminished breath sounds in right middle lobe; S1S2 auscultated; bowel sounds positive in all 4 quadrants; skin warm dry and intact. VS T 99.8F(37.7C); HR 110; RR 30 bpm; B/P 168/90; pulse oximeter is 87% on 100% non-rebreather; pain-0/10. Laboratory Report Lab Results Reference range ABG pH 7.2 7.35-7.45 ABG P02 65 mm Hg 75-100 mm Hg ABG PC02 51 mm Hg 35-45 mmHg ABG HC03 28 mEq/L 22-26 mEq/L WBC 5,600 cells/mm3 4.5 – 10.5 x 103 cells/mm3 Platelets 250,000/ mm3 140,000 to 450,000/ mm3 Potassium(serum) 4.0 mEq/L 3.5 to 5 mEq/L Sodium (serum) 140 mEq/L 135 to 145 mEq/L Magnesium 1.5 mEq/L 1.5 to 2.1 mEq/L Lactate level 4.5 mEq/L 0.5 to 2.2 mEq/L Blood culture Gram negative cocci Negative Urine culture pending Negative Sputum culture pending Negative What does the nurse determine is the priority for this client’s care?

Which of the following findings would the nurse assess in a patient diagnosed with Left Sided Heart Failure and  Pulmonary Edema? Select all that apply.

The nurse cares for a 78-year-old female admitted to the medical intensive care unit in respiratory distress. Nurses’ Notes   0900. Client was admitted to the ICU in respiratory distress after minimal response to high flow oxygen for a pulse oximeter reading of 83% in room air. Crackles heard bilaterally in lower lobes with diminished breath sounds in right middle lobe; S1S2 auscultated; bowel sounds positive in all 4 quadrants; skin warm dry and intact. VS T 99.8F(37.7C); HR 110; RR 30 bpm; B/P 168/90; pulse oximeter is 87% on 100% non-rebreather; pain-0/10. 0930. Client was intubated with #6 endotracheal tube and was placed on assist control mechanical ventilation, rate 14, Peep 5 mmHg, FIO2 60%. VS T 99.8F(37.7C); HR 110; RR 14; B/P 180/90; pulse oximeter is 96%. Client is restless. Laboratory Report Lab Results Reference range ABG pH 7.2 7.35-7.45 ABG P02 65 mm Hg 75-100 mm Hg ABG PC02 51 mm Hg 35-45 mmHg ABG HC03 28 mEq/L 22-26 mEq/L WBC 5,600 cells/mm3 4.5 – 10.5 x 103 cells/mm3 Platelets 250,000/ mm3 140,000 to 450,000/ mm3 Potassium(serum) 4.0 mEq/L 3.5 to 5 mEq/L Sodium (serum) 140 mEq/L 135 to 145 mEq/L Magnesium 1.5 mEq/L 1.5 to 2.1 mEq/L Lactate level 4.5 mEq/L 0.5 to 2.2 mEq/L Blood culture Gram negative cocci Negative Urine culture pending Negative Sputum culture pending Negative The client’s spouse enters the room and is able to visit for the first time. The​ client’s spouse asks the nurse what causes ARDS and is explaining direct injury ARDS vs Indirect Injury ARDS. Which etiology of direct injury to the lungs should the nurse include in the​ir education? 

The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment parameter is most important for the nurse to assess? Select all that apply

How many Liters would the nurse place the client on to implement the following MD order: Provide FiO2 28% to Keep patients O2 Satuation >92% (Only place the whole number, do not put L/min)

The ______________________________ law allowed the patrician classes and the plebian classes to intermarry.