The nurse is caring for a mechanically ventilated client wit…
The nurse is caring for a mechanically ventilated client with a traumatic brain injury who has an intracranial pressure (ICP) monitor in place. The current assessment findings are: BP 80/50 mm Hg, apical heart rate 60, respiratory rate 20, ICP 22 and temperature of 38*C. The clients CPP pressure = ______________
Read DetailsThe new medical-surgical floor nurse is rounding and finds t…
The new medical-surgical floor nurse is rounding and finds the client in bed, sitting in high Fowler’s position. The client is using accessory muscles, is very anxious and has a feeling of impending doom. The client’s vital signs are: BP 90/50 mm/Hg, apical rate of 110 beats per minute, and RR of 36 shallow and labored. Which of the following should the nurse perform next?
Read DetailsThe nurse is caring for a client who was just admitted to th…
The nurse is caring for a client who was just admitted to the ICU with an acute stroke. The client has a Glasgow Coma Scale (GCS) of 10 and is in high-fowler’s position with a non-rebreather mask connected to 100% oxygen. Which of the following nursing interventions is a priority in the client’s plan of care?
Read DetailsThe new medical-surgical floor nurse is rounding and finds t…
The new medical-surgical floor nurse is rounding and finds the client in bed, sitting in high Fowler’s position. The client is using accessory muscles, is very anxious and has a feeling of impending doom. The client’s vital signs are: BP 90/50 mm/Hg, apical rate of 110 beats per minute, and RR of 36 shallow and labored. Which of the following should the nurse perform next?
Read DetailsThe nurse is caring for a client who has undergone skin graf…
The nurse is caring for a client who has undergone skin grafting of the face and arms for burn wound treatment. In creating a care plan for this client, which of the following nursing diagnosis would be a priority for this client?
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