The nurse has established a goal to maintain ICP within the normal range for a client who had a craniotomy 12 hours ago. Which of the following interventions would be inappropriate?

The nurse is caring for the client who is in septic shock, newly intubated and on a ventilator. The assessment findings are: Mean Arterial Pressure (MAP) = 58 mm Hg, sinus tachycardia with frequent PVC’s on telemetry. Pulmonary Artery Catheter readings: Central Venous Pressure (CVP)= 1 mmHg, Pulmonary Artery (PA) pressure=12/6 mmHg, Systemic Vascular Resistance (SVR) of 670 dynes/sec/cm-5. Which of the following treatments would the nurse anticipate being ordered by the provider? Select all that apply.

The client has been admitted with a STEMI. The provider orders Nitroglycerine IV 5mcq/min. The client’s admission weight is 97.5kg. The pharmacy sends up a bag of Nitroglycerin with the following label (See Pic) The nurse will set the IV pump at ________ mL/hr  

The nurse is caring for a client with hypovolemic shock who has been receiving large amounts of IV fluids. Which of the following would be most important for the nurse to perform to evaluate the effectiveness of intravenous fluid therapy?

The nurse is caring for a client with respiratory distress. Which of the following assessments would be most concerning to the nurse?

The nurse is caring for a client at risk for developing Acute Respiratory Distress Syndrome (ARDS). Which of the following manifestations would the nurse expect to see in early ARDS?

The nurse is caring for a client with an electrical burn injury; with an entrance wound in the right hand and an exit wound in the left foot. After placing the client on 2 liters of oxygen via nasal cannula, the nurse’s next intervention is to do which of the following?

In clients with extensive burns, edema occurs in both burned and unburned areas because of which of the following?

Hold up your scrap paper at the end of the exam to the camera, and rip it up in front of the cameral. 

Based upon the rhythm below, which of the following interventions will the nurse perform first?