The nurse is educating a patient’s family regarding their loved one’s recent diagnosis of septic shock. Which of the following will the nurse include in the teaching plan?

A client diagnosed with antisocial personality disorder approaches the nurse and says “You’re so beautiful, are you married?” Which is the most appropriate response by the nurse?

A child with autism spectrum disorder (ASD) often has difficulty with trust. With this in mind, which nursing action would be most appropriate?

A client with facial burns asks the nurse if he will ever look the same. Which response is best for the nurse to provide?

  Peritoneal and blood cultures are sent to the lab and focused assessments are completed. IV Normal Saline is started at 100cc/hr. The following assessment data is obtained. Anxious and restless in bed Oriented to person and place Shallow depth of respirations Auscultated lung fields clear throughout 2+ radial pulses, 1+ pedal pulses Capillary refill >3 seconds Skin cool and pale Diminished bowel sounds Client denies chest pain, heartburn, and nausea Time 1600 1700 1745 2120 2230 0200 0615 0730 Unit Pre-op Surgery Post-op MS Vital signs Temperature 98.9° F (37.2° C) 99.5° F (37.5° C)     100.9° F (38.3° C) 101.6° F (38.7° C) 102.3° F (39.1° C) 102.5° F (39.2° C) Heart rate 89 beats/min 95 beats/min     88 beats/min 108 beats/min 116 beats/min 120 beats/min Cardiac rhythm NSR NSR     NSR ST ST ST  Blood pressure 145/67 mm Hg 126/60 mm Hg     120/60 mm Hg 108/57 mm Hg 95/51 mm Hg 90/48 mm Hg Respiratory rate 18 breaths/min 18 breaths/min     22 breaths/min 24 breaths/min 28 breaths/min 28 breaths/min O2 saturation 95% 94%     98% 92% 90% 90% O2 device None None     2L NC 2L NC 4L NC 50% VM Pain Denies Denies     Abdomen 4/10 Abdomen 4/10 Abdomen 6/10 Abdomen 6/10 Capillary blood glucose   148 mg/dL (8.2 mmol/L)   136 mg/dL (7.6 mmol/L) 186 mg/dL (10.33 mmol/L) 205 mg/dL (11.39 mmol/L) 260 mg/dL (14.4 mmol/L) Labs                 RBC   4.8 × 1012/L     4.9 × 1012/L     4.8 × 1012/L WBC   11,000/mm3 (11 109/L)     11,800/mm3 (11.8 × 109/L)     13,000/mm3 (13 × 109/L) Platelet   110,000/mm3 (110 × 109/L)     100,000/ mm3 (100 × 109/L)     90,000/ mm3 (90 × 109/L) BUN   72 mg/dL (25.71 mmol/L           79 mg/dL (28.21 mmol/L Creatinine   4.8 × 1012/L           6.3 × 1012/L APTT   33 sec           55 sec INR   1.3           1.7 Lactate               4.2 mmol/L (41.53 mg/dL) Arterial blood gas             pH               7.32 PaO2               60 mm Hg PaCO2               55 mm Hg HCO3−               20 mEq/L Cultures                 Peritoneal               Pending Blood               Pending   What is the most likely explanation for this client’s condition?

When caring for a patient with septic shock and possible multi-organ dysfunction syndrome (MODS), which assessment data obtained by the nurse will help confirm the diagnosis of MODS?

A client’s burn wound is being treated with enzymatic debridement. At this time the nurse would assess the client for

The provider orders Lovenox (enoxaparin) 85mg subcutaneous every 12 hours for venous thromboembolism prophylaxis. The medication is available as 60 mg per 0.6 mL. How many mL will the nurse draw up for the dose? Record answer to the hundredth.

What was the patient’s total intake for the 8 hour shift? patient drank 6 oz of water 100 mL of juice 0.9% NS at 100 mL per hour continuously.

A young woman who was a recent victim of sexual assault is brought into the emergency department by a friend. Which of the following is the priority nursing intervention?