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A 74-year-old client with a history of type 2 diabetes is admitted to the medical ICU with fever, tachycardia, and suspected sepsis from a urinary source. Initial management included: 30 mL/kg of IV lactated Ringer’s completed 2 hours ago Blood cultures drawn before initiation of IV piperacillin-tazobactam Continuous cardiac monitoring and arterial line placement Two hours after the initial fluid bolus, the nurse notes the following changes: Which findings suggest the client is progressing from sepsis to septic shock? Select all that apply.

A 42-year-old client was recently diagnosed with acute myeloid leukemia (AML) and is being discharged home after initial workup. The client is scheduled to begin induction chemotherapy next week. The nurse has provided discharge teaching on infection prevention, bleeding precautions, nutrition, follow-up, and activity. Before discharge, the nurse asks the client to verbalize key teaching points to evaluate understanding. Which client statements indicate a need for further education? Select all that apply.

A 68-year-old client is being discharged home after a 4-day hospitalization for an acute exacerbation of chronic heart failure (HFrEF, EF 35%). The client lives alone, is cognitively intact, and is being discharged on: Furosemide 40 mg PO daily Lisinopril 10 mg PO daily Metoprolol succinate 50 mg PO daily Spironolactone 25 mg PO daily Potassium chloride 20 mEq PO daily The nurse is developing the client’s discharge teaching plan. Which topics should the nurse include in the discharge teaching plan? Select all that apply.

A 61-year-old client with end-stage liver failure secondary to chronic hepatitis C is admitted to the medical unit for evaluation of worsening symptoms. The client appears jaundiced, has mild abdominal ascites, and is reported by family to be “not acting like themselves” with episodes of confusion over the past 2 days. Laboratory results: Lab Value Reference Range Serum albumin 2.6 g/dL 3.5–5.0 AST 92 U/L 10–40 Ammonia 124 mcg/dL 15–45 Total bilirubin 4.0 mg/dL 0.1–1.2 INR 1.8 0.9–1.1 Platelets 88,000/μL 150,000–400,000 Which laboratory value is most concerning and requires immediate intervention?

A 34-year-old client with a T4 spinal cord injury sustained 8 months ago is receiving care on a medical unit after being admitted for a urinary tract infection. The client performs clean intermittent self-catheterization every 6 hours at home but has not catheterized in 8 hours due to nausea and fatigue. The client calls the nurse using the call light and reports: “I have a pounding headache, I can’t see right, and my chest feels tight.” Assessment findings: BP: 204/112 mm Hg (baseline 108/68) HR: 52 bpm, regular RR: 20 SpO₂: 96% on room air Skin above the level of injury: flushed, warm, and diaphoretic Skin below the level of injury: pale, cool, with piloerection (“goosebumps”) Client reports blurred vision and nasal congestion Indwelling Foley is not in place; abdomen is palpably distended over the bladder Last bowel movement: 3 days ago What is the nurse’s priority action?

A 70-kg client with septic shock secondary to urosepsis has been receiving aggressive treatment in the ICU for the past hour, including: 30 mL/kg of IV lactated Ringer’s per the Surviving Sepsis Campaign bundle Broad-spectrum IV antibiotics (piperacillin-tazobactam) A norepinephrine infusion titrated to maintain MAP ≥ 65 mm Hg Admission values (1 hour ago): MAP: 58 mm Hg HR: 128 bpm Serum lactate: 4.8 mmol/L Urine output: 15 mL/hr Skin: mottled, cap refill > 4 sec The nurse is reviewing the chart to evaluate the client’s response to treatment. Which documented change best indicates that the client’s condition is improving?

A 76-year-old client is admitted to the telemetry unit for evaluation of a single syncopal episode that occurred yesterday at home. The client has since remained asymptomatic. On admission, the cardiac monitor displays: Regular rhythm HR: 48 bpm One P wave before each QRS complex PR interval: 0.18 seconds (normal) QRS duration: 0.08 seconds (normal) Current assessment: BP: 110/70 mm Hg RR: 16 SpO₂: 97% on room air Alert and oriented ×3 Denies dizziness, lightheadedness, chest pain, shortness of breath Warm, dry skin; no edema Medication list includes metoprolol 50 mg PO BID for hypertension Which action should the nurse take next?

A 68-year-old client is admitted to the medical unit with an acute exacerbation of COPD. The client reports increased dyspnea and a productive cough with yellow sputum for the past 3 days. Vital Signs: BP: 145/90 mm Hg HR: 105 bpm RR: 30 breaths/min, labored with audible wheezing Temp: 37.3°C (99.1°F) SpO₂: 88% on room air Laboratory Results: WBC: 12,000/mm³ pH: 7.35 PaCO₂: 50 mm Hg PaO₂: 60 mm Hg The provider has prescribed oxygen therapy, nebulized albuterol-ipratropium, IV methylprednisolone, and oral azithromycin.

A 54-year-old client is 2 days post-op from a right upper lobectomy and has a chest tube to water-seal drainage at −20 cm H₂O suction. While the nurse is assisting the client to reposition in bed, the chest tube is inadvertently pulled out of the insertion site. Current assessment: Client is alert and reports sudden sharp pain at the insertion site RR: 24 HR: 108 SpO₂: 94% on 2 L/min nasal cannula Insertion site is exposed to open air What is the nurse’s immediate action?

A 58-year-old client with end-stage liver cirrhosis secondary to alcohol use is admitted to the medical unit with hepatic encephalopathy. The client is receiving lactulose 30 mL every 6 hours with a goal of 3–4 soft bowel movements per day. Current assessment findings: Client reports difficulty concentrating and is slow to respond to questions Asterixis (flapping tremor) elicited when the client extends the wrists Drowsy and confused; oriented to person and place but not time Slow, irregular respirations with periods of apneic pauses BP: 118/74 HR: 86 SpO₂: 94% on room air Serum ammonia: 142 mcg/dL (normal 15–45) Which finding is most concerning and requires the nurse’s immediate attention?