A client who suffered burns in a house fire reports a headache and is not consistently oriented to time. Which intervention by the nurse is most appropriate?

A client who was extubated 2 hours ago is becoming increasingly restless. The last vital signs before extubation were pulse 88 beats/min, respirations 18 breaths/min, blood pressure 138/78 mm Hg, and PaCO2 45 mm Hg. Current vital signs include pulse 104 beats/min, respirations 26 breaths/min, blood pressure 140/80mm Hg, and PaCO2 62 mm Hg. The nurse would anticipate which of the following actions?

A patient is admitted to the burn unit with burns of the head, neck, chest, and back following a garage fire. Upon admission to the unit, the nurse auscultates wheezes in the patient’s lungs. One hour later, the wheezes cannot be heard, and lung sounds are decreased. The most appropriate action by the nurse is to

A client admitted with shock has a urinary output of 15 ml/hr. The nurse understands that the compensatory physiologic mechanism that leads to altered urinary output is

On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 56%, Hb 18.6 mg/dl (172 g/L), serum K+ 4.8 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Based on these findings, the nurse should plan to

Those with a pacemaker can have an MRI performed safely.

The nurse is caring for a patient in septic shock. What clinical manifestations would indicate the patient has acute organ dysfunction? (Select all that apply.)

A patient with a severe infection has developed septic shock. The patient’s blood pressure is 72/44, heart rate 130, respiration 22, oxygen saturation 96% on high-flow oxygen, and temperature 103.6 ‘F. The patient’s mean arterial pressure (MAP) is 53 mmHg. Based on these findings, the nurse knows that the patient is experiencing diminished tissue perfusion and needs immediate treatment to prevent organ dysfunction.  In regards to the pathophysiology of septic shock, what is occurring in the body that is leading to the decrease in tissue perfusion? Select all that apply

A patient who has just been admitted with septic shock has a BP of 70/46, pulse 136, respirations 32, temperature 104.0° F, and blood glucose 246 mg/dl. Which of the following interventions is the priority?

Which of the following assessment findings is the priority to report for a patient with sepsis?