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The nurse working in the intensive care unit hears an alarm coming from a client’s room. On entering the room, the nurse sees this rhythm displayed on the monitor. The nurse recognizes it as [rhythm] and should prepare to [intervention].

A nurse is caring for four clients who have been mechanically ventilated for more than 48 hours. Based on early signs of ventilator-associated pneumonia (VAP), which client should the nurse assess first? 

A nurse is caring for a client with a traumatic brain injury who has an intracranial pressure (ICP) monitoring device in place. The current ICP reading is elevated at 22 mmHg. Which action should the nurse take first? 

A 21-year-old college student is brought to the emergency department with suspected meningitis. Which of the following findings are consistent with acute bacterial meningitis? Select all that apply. 

The nurse is caring for a client in septic shock. What finding should the nurse anticipate when the client’s condition is in its compensatory stage?  

A client is brought to the emergency department after a high-speed motor vehicle accident. Diffuse axonal injury (DAI) is suspected. Which presentation is most characteristic of this type of brain injury   

A client with sepsis has had a urine output of 12 mL/hr over the past 2 hours. Vital signs are BP 88/52 mm Hg, HR 112/min, and the client appears slightly confused. What is the nurse’s best immediate action? 

A nurse is caring for clients in the medical-surgical unit. The nurse understands which client is most at risk for developing a pulmonary embolism.  

A 58-year-old female in a severe motor vehicle accident is admitted to the ICU with fractured ribs. Muffled heart sounds, tracheal deviation, and absent breath sounds on anterior and posterior left lower chest wall are noted. The client is most likely experiencing which condition? 

Jungmin is an active 23-year-old college student. She was brought into the ER after being hit by a car. Jungmin suffered extensive blood loss, and the ER doctors felt she might need a transfusion. You, as the nurse on duty that day, should start typing her blood. Jungmin’s blood typing has been completed, as shown in the image. This meant she should be transfused with which type of blood? Select all that apply.