Blog

An immunocompromised older adult has developed a urinary tract infection and the care team recognizes the need to prevent an exacerbation of the client’s infection that could result in urosepsis and septic shock. What action should the nurse perform to reduce the client’s risk of septic shock?

A patient is being cared for in the Neurological Intensive Care Unit following a spinal cord injury. Which of the following assessment findings indicate the patient may be experiencing spinal shock?

The new patient was in a motor vehicle trauma and sustained a blunt force blow to the chest from the steering wheel. He arrives at the ER with complaints of left sided chest pain on inspiration. He has dyspnea, pallor and his pulse ox is 88%. The rest of his VS PR 130, RR 28, and BP 160/94. The triage nurse understands to prioritize which interventions for this client?

An emergency department nurse has just admitted a client with a burn. The burn area is the anterior upper chest and left anterior arm. Using the rule of nine, what would be the extent of the burn injury?

A nurse is caring for a client who was hit on the left side of the head with a baseball bat. Which of the following assessments should the nurse perform?

An ED nurse is triaging clients according to the Emergency Severity Index (ESI). When assigning clients to a triage level, the nurse will consider the clients’ acuity as well as what other variable?

A client is receiving a unit of PRBC due to GI bleeding. The nurse assesses the client after 15 minutes and the client complains of flank pain develops urticaria and shortness of breath.  The nurse suspects [condition]. The nurses priority action is [priority] and to monitor [parameter]  

The nurse is caring for a client with a traumatic brain injury receiving dexamethasone (Decadron) 4 mg IV every 6 hours. The client’s vital signs are Temperature: 99.0°F BP: 160/90 HR: 120 Respirations: 16 O2 Sat: 95%. Yesterday the client weighed: 67.2 kg. Which of the following assessment information would require immediate intervention?

The nurse is caring for a client in the ICU whose condition is deteriorating. The nurse receives orders to initiate an infusion of dobutamine. What would be the priority assessment and interventions specific to the administration of vasoactive medications? Select all that apply.

A client presents to the emergency department with complaints of generalized weakness. The nurse suspects systemic inflammatory response syndrome. What are expected additional findings upon assessment? Select All That Apply.