Chief Complaint:The patient reports feeling fatigued and experiencing frequent headaches for the past week. They also report generalized muscle weakness, which has worsened over the past few days. The patient notes that they have gained approximately 6 pounds (2.72 kg) over the last 5 days and states, “I need to sleep in my recliner at night because lying flat makes it hard to breathe.” Past Medical History: Hypertension Type 2 Diabetes Mellitus CHF Vital Signs at Admission: Blood Pressure: 120/80 Pulse: 104 bpm (apical, regular) Respiratory Rate: 24 breaths/min Temperature: 98 oral O2 Saturation: 95% RA The nurse collaborates with the team on the plan of care.  Select 4 goals the nurse recognizes must be included in the plan of care.

Hypovolemic shock occurs when there is low fluid volume in the:

Order:  potassium chloride 30 mEq po once per day Stock:  potassium chloride labeled 20 mEq/15 mL How many mL will you administer (round to the nearest tenth)

A nursing report on a newly admitted patient who is profoundly hard of hearing says that the patient is confused and difficult to assess because she does not appropriately respond to questions or sometimes fails to respond at all. What should be the first action of the oncoming nurse?

Assessment of a burn victim leads a nurse to suspect an inhalation injury. The observation that should indicate such an injury would be _____.

What is shock?

Order:  gentamycin 0.65 mg IM Stock:  vial of gentamycin 20 mg/2 mL How many mL will you administer (round to the nearest hundreth)

You are caring for a patient that had an a left knee replacement.  She is complaining of shortness of breath and pain in her chest.  You suspect she may have a pulmonary embolism and know that if you do not intervene she could go into:

A physician orders an infusion of 1000 mL of 5% dextrose in 0.45% NS to be completed in 10 hours. The IV delivery system’s drop factor is 20 gtt. How many mL/hr should the nurse set the electronic infusion pump to deliver the infusion?

Which of the following are signs of shock?  (select all that apply)