A nurse is caring for a client in the ICU with severe sepsis…
A nurse is caring for a client in the ICU with severe sepsis. Over the past 24 hours, the client has developed hypotension, oliguria, confusion, and increasing oxygen requirements.Which set of findings is most consistent with progression to multiple organ dysfunction syndrome (MODS)?
Read DetailsA client who has undergone left carotid artery angioplasty a…
A client who has undergone left carotid artery angioplasty and stent placement following a cerebrovascular accident (CVA) returns to the unit. The nurse is monitoring for potential complications. Which assessment would be the most concerning?
Read DetailsA client on mechanical ventilation has been receiving an FiO…
A client on mechanical ventilation has been receiving an FiO₂ of 100% for 48 hours. The nurse notes increasing restlessness, worsening dyspnea, a nonproductive cough, crackles throughout the lungs, and a decreasing PaO₂ despite the high oxygen concentration. The provider suspects oxygen toxicity. Which priority action should the nurse anticipate?
Read DetailsA client had a chest tube inserted four hours ago after a ro…
A client had a chest tube inserted four hours ago after a routine thoracentesis due to pleural effusion. During the current assessment, the nurse notes that the chest tube has drained 300 mL of bright red blood over the past hour. The client is restless and has cool, pale skin. Vital signs are heart rate 118 bpm, blood pressure 112/74 mmHg, and respiratory rate 22 breaths/min. Which action should the nurse take first?
Read DetailsA nurse is caring for a client newly admitted with suspected…
A nurse is caring for a client newly admitted with suspected sepsis related to a severe kidney infection. The client is alert, oxygen saturation is 96% on room air, and blood pressure is 114/74 mm Hg. The nurse has just finished drawing two sets of blood cultures. Which intervention is the highest priority for the nurse to complete next?
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