On admission to the post anesthesia care unit (PACU), the client’s blood pressure was 128/75 mmHg, Heart Rate 80 beats per minute, alert and oriented.  Thirty minutes later, the blood pressure decreases to 82/55 mmHg with a pulse of 125 beats per minute.  The nurse assesses the client drowsy, confused, restless, clammy and diaphoretic skin.  Which intervention should the nurse implement first?

The nurse is a caring for a client postoperatively. The client reports nausea and begins to vomit a large amount of fluid.  What should the nurse do next in safety of the client? 

The nurse assesses a client with a positive Chvostek’s sign.  The patient reports numbness and tingling in their extremities. What should the nurse recommend an order of?

After an ordered removal of a client’s chest tube due to lung re-expansion, the nurse anticipates the health care provider to apply which type of dressing to the wound site?

A client with Type 2 Diabetes Mellitus has been well controlled with insulin injections and has been NPO since midnight before having a mastectomy. The client is receiving intravenous fluids with dextrose. The nurse has an order to give insulin per correctional sliding scale.  What is the next best action of the nurse?

What would the nurse expect to initially assess in a client experiencing acute respiratory failure?

The nurse is obtaining a daily weight on a client who was admitted 3 days earlier and notices that the client has gained 5 pounds since admission. What is the priority action of the nurse?

The health care provider removed the chest tube due to lung re-expansion. The health care provider placed a dressing over the wound site. What is important for the nurse to assess if a pneumothorax reoccurs? 

The nurse is caring for a client with a magnesium level of 0.8 mEq/L. The nurse should closely monitor the client’s cardiac rhythm for: 

The nurse is caring for a client with vomiting and diarrhea.  Which signs and symptoms would the nurse expect to assess with the client having fluid deficit? (Select all that apply). Directions: See the list of signs and symptoms below and select the most appropriate signs and symptoms. 1. Full, bounding pulse 2. Heart rate 130 beats per minute 3. Weakness, dizziness 4. Blood pressure 160/90 mmHg 5. Crackles throughout all lung fields