The nurse is caring for a client with increased intracranial pressure. The nurse would note which of the following manifestations associated with Cushing’s triad?

The nurse is caring for a client with increased intracranial pressure (ICP). The nurse knows that one of the earliest signs of increased ICP is which one of the following?

Ten minutes following administration of an antibiotic, the nurse assesses a client to have edematous lips, hoarseness, and inspiratory stridor. Assessment reveal:  Pulse 130 beats/min, and RR 32 breaths/min. After administration of epinephrine, the nurse would anticipate which of the following outcomes that best demonstrates effectiveness of the medication?

The nurse is caring for a client who is mechanically ventilated. In order to reduce the client’s risk of ventilator-associated pneumonia (VAP), which intervention should the nurse prioritize?

On admission to the burn unit, the client with an approximate 25% Total Body Surface Area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL, serum K+ 4.9 mEq/L, serum Na+ 155 mEq/L, and serum osmolality 420 mOsmol/kg. Which provider orders will the nurse perform next?

The nurse is caring for a client with acute kidney injury with a potassium level of 7.1 mmol/L. Assessment of the client reveals: S3 heart sound, neck vein distension, BP 130/95 and a telemetry monitor that shows sinus rhythm of 96 beats per minute with frequent premature ventricular contractions (PVC’s). The nurse would perform which of the following interventions first?

The nurse is caring for a mechanically ventilated client with a sustained ICP of 22 mm/Hg. The nurse needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene care, and reposition the client to the left side. Which of the following would the nurse do that demonstrates understanding of the client’s current medical condition?

The nurse is caring for a client with acute pancreatitis. As part of the care plan for this client, which of the following nursing interventions would be inappropriate to include?

Which of the following is the best interpretation of the rhythm shown below?

Which of the following is the best interpretation of the rhythm shown below?