An unconscious adult is admitted to the Emergency Department. The client is hemorrhaging and in hypovolemic shock. The HCP (healthcare provider) ordered a blood transfusion stat.  The client’s spouse states “My wife is a Jehovah’s Witness and should not receive a blood transfusion”.  What is the nurse’s best action?

A client is on neutropenic precautions following treatment for acute lymphocytic leukemia and now presents with hypotension, tachycardia and an elevated temperature.  The nurse notifies the HCP. Which order from the HCP would be the nurse’s priority intervention?

A nurse is caring for a client diagnosed with a pneumothorax who had a chest tube inserted 4 hours prior.  There is vigorous bubbling in the water seal chamber of the chest tube drainage system. What is the nurse’s best action?

You are administering heparin and following the protocol below for a client weighing 189 lbs. The order is to administer an initial heparin bolus IV followed by a titrated IV infusion. Round to the tenths place. HEPARIN PROTOCOL Initial bolus- 50 units/kg Initial rate – 18 units/kg/hr Obtain a PTT every 6 hours, and adjust dosage and rate as follows: If  PTT is less than 35 secs:      Repeat bolus with 80 units/kg and increase the rate by 4 units/kg/hr. If  PTT is 36 to 44 seconds:       Repeat bolus with 40 units/kg and increase the rate by 2 units/kg/hr. If  PTT is 45 to 75 seconds:       Continue current rate. If  PTT is 76 to 90 seconds:       If  PTT is 76 to 90 seconds:          Decrease rate by 2 units/kg/hr. If  PTT is greater than 90 secs: Hold the heparin for 1 hour and decrease rate by 3 units/kg/hr. Available (for bolus)  – heparin 1,000 units/mLAvailable (for infusion) –  heparin 25,000 units in 250 mL D5W    What rate will the nurse set the pump at for the titrated heparin IV infusion in response to the PTT of 40 secs? 

The nurse is caring for a client who had transurethral resection of the prostate (TURP) 1 day ago, with continuous bladder irrigation (CBI). Which assessment findings does the nurse expect? 

The nurse is performing an assessment on a client who was just brought to the ED complaining of fatigue. Upon assessment, the nurse observes a large amount of bruising on the extremities, fever, and tenderness localized in the left upper quadrant. A health history reveals frequent infections for the past 2 months. Laboratory tests indicate severe anemia, significant neutropenia, and thrombocytopenia. Based on the symptoms, what could be the client’s diagnosis? 

Which statement by a 32-year old client newly diagnosed with Stage I breast cancer indicates to the nurse that the client understands her role in planning care? 

Identify which laboratory test should be ordered for each client complaint. Each laboratory test can only be used 1 time.

The nurse is monitoring a client who has a transdermal fentanyl patch in place for pain control related to cancer.  The nurse is teachng the new graduate nurse about interventions when administering this medication. The nurse knows the teaching was effective when the new graduate nurse states the following?    

The nurse is preparing to assess a client whose chart documents that the client experienced extravasation when receiving the vesicant vincristine during the previous shift 4 hours ago. The documentation also notes that an antidote was administered immediately. The nurse prepares to assess the skin for which finding?