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The client is diagnosed with mitral stenosis and new-onset atrial fibrillation. Which of the following interventions could the nurse delegate to the unlicensed assistive personnel? Select all that apply.

The nurse is caring for the client with cerebral edema with a Glasgow Coma Scale (GCS) of 5 and an intracerebral pressure reading (ICP) of 21 mm/Hg. Which of the following medications ordered by the healthcare provider would be inappropriate to administer to the client?

An acutely ill client is being cared for in the critical care unit. The client is delirious and is exhibiting signs of significant anxiety. The nurse should recognize that the client is at greatest risk for which of the following nursing diagnosis?

The client is diagnosed with mitral stenosis and new-onset atrial fibrillation. Which of the following interventions could the nurse delegate to the unlicensed assistive personnel? Select all that apply.

The nurse is caring for a spinal cord injury client in neurogenic shock. Several liters of IV fluids have been administered without improvement of the patient’s condition. Current vital signs assessed by the nurse include: B/P 60/40 mmHg, Pulse 132 beats/min, RR 28 breaths/min, and rectal temperature of 35.5°C. Which of the following provider orders should the nurse perform first?

The nurse is caring for a client having an episode of status epilepticus. Vital signs assessed by the nurse include blood pressure 160/100 mmHg, heart rate 145 beats/min, respiratory rate 36 breaths/min, SpO2 96% on 100% supplemental oxygen by non-rebreather mask. After establishing an IV line, which order by the healthcare provider should the nurse implement first?

The nurse is caring for a spinal cord injury client in neurogenic shock. Several liters of IV fluids have been administered without improvement of the patient’s condition. Current vital signs assessed by the nurse include: B/P 60/40 mmHg, Pulse 132 beats/min, RR 28 breaths/min, and rectal temperature of 35.5°C. Which of the following provider orders should the nurse perform first?

Which of the following nursing diagnoses and interventions has the highest priority while treating a client with Guillain-Barre syndrome?

The alert and oriented client with a closed head injury has a blood pressure 130/90 mm/Hg, pulse 64 beats/min, RR 18 breaths/min, and a Temp. of 38.8° C. To reduce the risk of increased intracranial pressure (ICP) on this client, which of the following is the priority nursing intervention?

The nurse is caring for a client with a left sided chest tube that is experiencing manifestations of a tension pneumothorax. The nurse knows that a client with a chest tube is at risk for tension pneumothorax if which of the following scenarios is present?