A nurse is managing care for a patient with third-degree burns over 35% of their total body surface area (TBSA), admitted 6 hours ago. The nurse notes the following assessment findings: blood pressure 88/54 mmHg, heart rate 130 bpm, urine output 15 mL/hr, and serum potassium level of 6.0 mEq/L. Which intervention should the nurse implement first?

A 28-year-old male is admitted to the ICU following a traumatic brain injury (TBI) from a motor vehicle accident. His Glasgow Coma Scale (GCS) score is 9, blood pressure 130/80 mmHg, heart rate 85 bpm, respiratory rate 18 breaths per minute, and oxygen saturation 94% on room air. The nurse notes that the patient’s pupils are equal, round, and reactive to light, but he is increasingly lethargic. A CT scan shows signs of cerebral edema, and the healthcare provider suspects increased intracranial pressure (ICP). Which of the following actions should the nurse take to best manage the patient’s increased intracranial pressure (ICP)?

A nurse is monitoring a patient who has just started receiving a unit of packed red blood cells (PRBCs). The patient complains of chills, low back pain, and shortness of breath 15 minutes after the transfusion begins. What is the nurse’s priority action?

The nurse is assessing a patient admitted with acute respiratory failure. The patient is drowsy, has a respiratory rate of 8 breaths per minute, and an oxygen saturation of 85% on room air. What is the nurse’s priority action?

Two days after surgery to amputate the left lower leg, a client reports pain in the missing extremity. Which action by the nurse is most appropriate?

A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21 (Range 7.35 – 7.45) PaCO2 64 mm Hg ( Range 35 – 45mm Hg) HCO3 24 mm Hg ( Range 22 – 26 mm Hg)   Which condition does the ABG reflect?

A patient who sustained a C5 spinal cord injury 4 hours ago is being assessed. Which of the following nursing diagnoses should the nurse prioritize?

A nurses is working with a client with anemia. What findings would the nurse expect on assessment? Select all that apply.

A nurse is assessing a patient with chronic glomerulonephritis who reports fatigue, swelling in the legs, and decreased urine output. The nurse notes the following findings: blood pressure 168/96 mmHg, heart rate 88 bpm, respiratory rate 22 breaths/min, bilateral pitting edema in the lower extremities, and crackles in the lung bases. Laboratory results include a BUN of 38 mg/dL (normal range 7-20), creatinine of 3.2 mg/dL (normal range 0.7 – 1.3 mg/dL), and serum potassium of 6.2 mEq/L (normal range 3.5 – 5.0 mEq/L). Which assessment finding is the priority for the nurse to address?

When measured with a graduated glass cylinder, water makes a concave meniscus. Mercury, on the other hand, makes a convex meniscus (see image below). Why does it do this?