A patient admitted with sepsis has had several episodes of severe hypotension. Lab results indicate a BUN of 30 mg/dl and serum creatinine of 2.0 mg/dl. The urinalysis reveals cellular casts and debris indicating sloughing of cells. The nurse knows these findings are consistent with:

A client who has massive trauma is admitted to the ICU. Which pathophysiologic event associated with trauma would cause the nurse to intervene to protect the client’s immune system?

Following a myocardial infarction, a patient develops cardiogenic shock with fluid overload. The patient has metabolic acidosis and ECG changes characteristic of hyperkalemia in addition to azotemia and a BP of 92/48. The nurse recognizes that treatment of the patient most likely will involve:

 A patient has full-thickness burns of the entire anterior chest area, entire right arm, and deep partial-thickness burns. Based on the rule of nines, which estimate of total body surface area burn would the nurse record?

Cardiac monitoring is initiated for a patient with Acute Kidney Injury. The nurse recognizes that this measure is important to identify:

An elderly man woke up coughing to find his apartment was on fire. He was able to escape out of the window where the first responders transported him to the local ER. You are the nurse receiving this patient in the ER. Your assessment reveals: AAOx3, BP 102/80, HR 110, Resp 24, Temp 98.9, pulse ox 99% on RA. The patient starts coughing when trying to answer your questions and it has a seal-like sound.  What is your number one nursing diagnosis for this patient? What is your priority nursing intervention?

A patient, in the intensive care unit, has been NPO for several days. The nurse is unable to assess bowel sounds. What should be included in the plan to support this patient’s nutritional needs?

A client who developed acute kidney failure while hospitalized has been started on hemodialysis. Which change in nutritional therapy would the nurse anticipate?

Multiply.-12 ∙ 2

For Socrates, a good life required knowledge of evil.