Health

A client returns to the intensive care unit after having a permanent pacemaker inserted Which finding should the nurse observe for during the immediate hours after insertion? Beck's triad. Burns around the site. Hypothermia. Cardiac arrhythmia.

An older client is admitted to the intensive care unit after a small bowel resection.The postoperative prescriptions include a patient-controlled analgesia (PCA) device with morphine titrated per protocol. Which information should the nurse provide the client about the use of a PCA device? Push the button when pain is first experienced instead of waiting until pain is unbearable. Family members or visitors can press the button when the client grimaces in pain. Press the button every 15 minutes even when pain is not present. Delay pressing the button until the pain level is an 8 on a scale of I to 10.

The nurse assists the healthcare provider with the insertion of a pulmonary artery (PA)catheter for a client with cardiogenic shock.Which action is most important for the nurse to take to prevent life -threatening complications from pulmonary artery monitoring? Fast-flush the PA distal port for no more than 2 seconds. Avoid infusing blood products through the PA catheter. Clear the pressure tubing of any blood after withdrawing a sample. Maintain 300 mmHg of pressure around the bag attached to the tubing.

The nurse is caring for a client in the intensive care unit with type 1 diabetes mellitus who has a blood glucose level of 600 mg/dL(33.3mmol/L) .Which clinical manifestation is most important for the nurse to report to the healthcare provider if the blood sugar continues to rise? Change in level of consciousness. Increase in urinary output. Onset of Kussmaul respirations. Decrease in serum potassium level.

The nurse is caring for a client who was recently extubated in the postanesthesia I care unit. The client has humidified oxygen per mask and suddenly develops stridor and respiratory difficulty. Which action should the nurse implement? Call the rapid response team for emergency airway management. Encourage the client to take deep breaths, cough , and expectorate. Increase the flow rate of the humidified oxygen. Suction the client's mouth and oropharynx thoroughly.

The nurse is preparing a client with acute kidney injury for hemodialysis in the intensive care unit (ICU). Which assessment should the nurse obtain prior to beginning the procedure? Weight using the ICU bed scales. Arteriovenous fistul site. Capillary refill. Urine color and clarity.

A client with chronic kidney disease (CKD) is admitted for strict fluid restriction.Which assessment finding requires additional nursing action? Crackles in the lungs. Decreased serum creatinine level. Increased weakness. Increase in serum potassium.

Minutes after the nurse administers 3 .0 mg sublingual dose of nitroglycern, a client's blood pressure suddenly drops from 160/90mmHg to 60/40mmHg and the client reports crushing chest pain The client is experiencing severe nausea, dizziness, and left arm numbness.Which intervention should the nurse implement? Give a PRN antiemetic medication. Administer a second dose of nitroglycerin. Infuse a rapid 0.9% normal saline bolus. Apply external pacemaker pads to chest.

The nurse is caring for a client admitted to the intensive care unit with traumatic brain injury from a motor vehicle collision. The client is experiencing increased intracranial pressure.The healthcare provider explains to the family that the client needs to go to surgery for a decompressive craniectomy. Which information should the nurse explain to the client? An overlying cranial bone flap is removed to allow swelling brain tissue to expand. The procedure uses a magnetic resonance imaging-guided laser ablation. An opening into the skull is made to remove damage tissue. A burr hole is drilled through the cranial bone to evacuate blood.

A client who is hypotensive is receiving an IV infusion of dopamine 10mcg/kg/minute through a peripheral line. The client reports burning at the IV site .Which action should the nurse implement? Stop the infusion and notify the healthcare provider of the findings. Check the line for blood return and irrigate the peripheral IV catheter. Apply a cold compress to the site and continue the infusion. Slow the infusion and add a secondary IV of 0.9% sodium chloride.