An immunocompromised elderly patient has developed a urinary tract infection and the care team recognizes the need to prevent an exacerbation of the client’s infection that could result in urosepsis and septic shock. What action should the nurse perform to reduce the client’s risk of septic shock?

A client sustains a fractured right humerus in an automobile accident. The arm is edematous, the client states not being able to move or feel the fingers, and the nurse does not feel a pulse. What condition should the nurse be concerned about that requires emergency measures?

A 28-year-old male is admitted to the ICU following a traumatic brain injury (TBI) from a motor vehicle accident. His Glasgow Coma Scale (GCS) score is 9, blood pressure 130/80 mmHg, heart rate 85 bpm, respiratory rate 18 breaths per minute, and oxygen saturation 94% on room air. The nurse notes that the patient’s pupils are equal, round, and reactive to light, but he is increasingly lethargic. A CT scan shows signs of cerebral edema, and the healthcare provider suspects increased intracranial pressure (ICP). Which of the following actions should the nurse take to best manage the patient’s increased intracranial pressure (ICP)?

A nurse is caring for a patient diagnosed with a pulmonary embolism who is receiving continuous intravenous heparin therapy. The patient suddenly reports worsening shortness of breath and chest pain. The nurse assesses the following: SpO2 88% on 4 L/min via nasal cannula, respiratory rate 28, HR 122, and BP 88/56. Which action should the nurse implement first?

A 78-year-old patient with terminal cancer is admitted to the hospice unit for end-of-life care. The patient is alert but expresses concern about pain management, stating, “I can’t stand this pain anymore and I don’t want to be a burden to anyone.” Patient rates his pain currently as 9 out of 10.  The nurse is preparing the patient’s care plan. Which of the following interventions should the nurse prioritize?

A 42-year-old patient is admitted to the hospital with a diagnosis of Cushing syndrome. During the nurse’s assessment, the patient reports extreme fatigue, weight gain, and frequent bruising. The nurse observes truncal obesity, a round face, and purple striae on the abdomen. Which nursing intervention is the priority for this patient?

The nurse is caring for a client in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS) with likely progression to the irreversible stage. The nurse’s plan of care should include which intervention?

A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21 (Range 7.35 – 7.45) PaCO2 64 mm Hg ( Range 35 – 45mm Hg) HCO3 24 mm Hg ( Range 22 – 26 mm Hg)   Which condition does the ABG reflect?

A triage nurse is helping to sort patients during a natural disaster. Which of the following patients would be categorized in the “immediate” or red level?

The nurse is monitoring a 46 year old male who underwent esophageal variceal banding 2 hours ago. Which assessment finding is the most concerning?