The nurse is evaluating the effectiveness of fluid resuscitation on the client who experienced a severe burn 12 hours ago. Which of the following assessments indicate that adequate fluid replacement is being achieved?

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 anticipates which of the following assessment findings related to fluid volume deficit on a client who has had 4 days of nausea, vomiting and fever? Select all that apply.

The nurse is caring for the client who had a myocardial infarction. The client’s telemetry was sinus rhythm but now has changed to the rhythm below. The client complains of dizziness, SOB, and has a B/P of 76/42 mm Hg. The nurse should perform which of the following interventions first?

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?