The nurse is caring for a client with burns to the hands and feet. The nurse plans care to include which of the following?

Based upon the rhythm below, which of the following interventions will the nurse perform first?

A client is admitted to the cardiac care unit with cardiogenic shock. The nurse assesses the client to be diaphoretic and tachypneic, with bilateral crackles throughout both lung fields. Following insertion of a pulmonary artery catheter, which hemodynamic values will the nurse most likely find?

The nurse is caring for a client who has a diminished level of consciousness and who is mechanically ventilated. While performing a pain assessment on this client, the nurse notes the client’s arms bilaterally flex and adduct, and the legs extend and internally rotate when pressure is applied to the client’s nail beds. The nurse knows that this is which one of the following?

The nurse is caring for a client who is being discharged after an episode of Guillain-Barre (GB). Which of the following providers should the nurse make sure is contacted to assist the client in recovery from this disease?

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 = ______________    

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?

The nurse is caring for a client receiving total parenteral nutrition (TPN). The nurse understands that  which of the following manifestations is associated with complications from TPN?  

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?

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?