The nurse is caring for a client with an Aortic Aneurysm in the Intensive Care Unit.  The nurse is keeping tight control of the blood pressure with intravenous Labetalol (Trandate). The client’s vital signs: 115/70 mmHg, Heart rate 65 beats per minute, SpO2 98%, Respiratory Rate 20 breaths per minute. The client starts reporting severe back and abdominal pain. In regards to the client’s signs and symptoms, what is the most appropriate action of the nurse?

A 80 year-old client who is diagnosed with bilateral lower lobe pneumonia is admitted to the intensive care unit. The patient has a history of Type 2 Diabetes Mellitus. On assessment, you note the client’s head of bed is at 30 degrees, has a respiratory rate of 30 breaths per minute, oxygen saturation 88% on 2L/min nasal cannula, is alert & oriented, and has a productive cough with green/yellowish sputum. The client is currently receiving intravenous steroids and a nebulizer. Which of the following nursing interventions will you provide to this based on your assessment findings (Select all that apply): 

The nurse is caring for a pediatric client admitted for nausea, vomiting and diarrhea.  The nurse assesses tachycardia, delayed capillary refill and hypotension. Which type of shock does the nurse most likely suspect?

An 10-month-old baby presents to the emergency room with nausea and vomiting.  On assessment the nurse notes the capillary refill is >3 seconds, heart rate 180 beats per minute, and SpO2 98%. What is the most appropriate nursing intervention?

The client is complaining of abdominal pain and back pain.  They appear restless and diaphoretic. The nurse auscultates a bruit in the abdomen.  The client’s vital signs: Blood pressure 95/60 mmHg, Heart rate 140 beats per minute, Respiratory Rate 30 breaths per minute, SpO2 88%.  The nurse suspects the client is experiencing a: 

The nurse is caring for a client with a history of Cystic Fibrosis. Upon assessment, the nurse notes: Yellowing of the sclera, reports nausea and vomiting. The vital signs: 110/85 mmHg, heart rate 110 beats per minute, SpO2 98% on Nasal Cannula 2L/min.  The nurse should review the Medication Administration Record (MAR) for this type of medication and notify the provider: 

The nurse started Dobutamine intravenous continuously for a client that experienced an Acute Myocardial Infarction and consequently heart failure. The nurse recognizes the mechanism of action of this medication is:  

The nurse is caring for a client with an Intra-Aortic Balloon Pump (IABP) in the Intensive Care Unit (ICU).  The nurse assesses the insertion site of the IABP via the left femoral artery.  The nurse then assesses the client’s pedal pulses. The nurse notes the left pedal pulse and diminished in strength and the foot appears pallor.  What is the most appropriate action based on the assessment findings? 

Social Security (e.g., for retirement):

The client is admitted with shortness of breath, diaphoresis and fatigue and blood pressure 85/50 mmHg and heart rate 50 beats per minute. The nurse connects the cardiac monitor to the client and recognizes the client is in Second Degree Heart Block Type 2.  What is the most appropriate action of the nurse?