The nurse is caring for a client with a traumatic brain inju…

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%.   Which of the following assessment information would require immediate intervention?

A client in hypovolemic shock is receiving a unit of PRBC du…

A client in hypovolemic shock 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]