Scenario Continuation (Part 3)Thirty minutes after insertion…
Scenario Continuation (Part 3)Thirty minutes after insertion of the chest tube, the nurse notices rapid deterioration in the patient.Assessment FindingsExtreme dyspnea, agitationRR 38SpO₂ 80%, despite high‑flow O₂Chest tube shows no tidaling or bubblingTracheal deviation to the rightJVDAbsent breath sounds on the leftBP 82/48, HR 134
Read DetailsA client with a known abdominal aortic aneurysm (AAA) sudden…
A client with a known abdominal aortic aneurysm (AAA) suddenly reports severe back and flank pain accompanied by nausea and a firm, pulsatile abdominal mass. The nurse reviews the client’s recent vital‑sign trends shown below. AAA vitals.PNG Which action should the nurse take first?
Read DetailsA client with a known abdominal aortic aneurysm (AAA) sudden…
A client with a known abdominal aortic aneurysm (AAA) suddenly reports severe back and flank pain accompanied by nausea and a firm, pulsatile abdominal mass. The nurse reviews the client’s recent vital‑sign trends shown below. AAA vitals.PNG Based on this information, which condition is the most likely cause of the client’s symptoms?
Read DetailsScenario Continuation (Part 2)The patient is placed on high‑…
Scenario Continuation (Part 2)The patient is placed on high‑flow O₂ and analgesics have been administered for pain management. The nurse assists with chest tube insertion for treatment of a small pneumothorax (identified on chest X-ray).Post‑Chest Tube Insertion Assessment Findings:28 Fr chest tube placed left mid‑axillaryTidaling with breathing; intermittent bubbling40 mL bloody drainage initiallyBreath sounds improved but still diminishedRR now 26, SpO₂ improves to 92% on 6 L NCPain reduced to 4/10
Read DetailsA client is admitted to the cardiac intensive care unit with…
A client is admitted to the cardiac intensive care unit with cardiogenic shock and has an intra-aortic balloon pump (IABP) inserted via the femoral artery. The nurse understands that this therapy places the client at risk for thromboembolism.Which nursing interventions are appropriate to monitor for and prevent thromboembolism in this client? Select all that apply
Read DetailsYou are reviewing a chart for a patient admitted with possib…
You are reviewing a chart for a patient admitted with possible respiratory failure and a high PaCO2, which assessment information should be immediately reported to the health care provider? Use the hot spot to select ONE of the provided options.
Read DetailsA Patient is receiving a neuromuscular blocking agent (NMBA)…
A Patient is receiving a neuromuscular blocking agent (NMBA), or “paralytic” drug, to improve synchrony with mechanical ventilation. While reviewing the plan of care, which finding should prompt the nurse to intervene immediately?
Read DetailsA client in the ICU is being treated for hemodynamic instabi…
A client in the ICU is being treated for hemodynamic instability related to severe pump failure after an extensive myocardial infarction. The client is receiving maximum doses of vasopressors and mechanical ventilation. Despite aggressive treatment, the client’s hemodynamic values continue to decline. Which assessment finding most strongly indicates the client may be entering the refractory stage of shock?
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