1. A male client with d. Increase the infusion rate of Lactated Ringer's
stomach cancer returns to solution.
the unit following a total
gastrectomy. He has a
nasogastric tube to suction
and is receiving Lactated
Ringer's solution at 75
mL/hour IV. One hour after
admission to the unit, the
nurse notes 300 mL of
blood in the suction
canister, the client's heart
rate is 155 beats/minute,
and his blood pressure is
78/48 mmHg. In addition to
reporting the finding to the
surgeon. Which action
should the nurse implement
first?
,2. an adult male who fell 20 a. Add sterile water to the suction control chamber.
feet from the roof of this
home has multiple injuries,
including a right
pneumothorax. Chest tubes
were inserted in the
emergency department
prior to his transfer to the
intensive care unit (ICU). the
nurse notes that the suction
control chamber is
bubbling at the
- 10 cm H2O mark, with
fluctuation in the water seal,
and over the past hour 75
ml of bright red blood is
measured in the collection
chamber. Which
intervention should the
nurse implement?
3. A client who received c. Begin supplemental oxygen.
hemodialysis yesterday is
experiencing a blood
pressure of 200/100 mmHg,
heart rate 110 beats/minute,
and respiratory rate 36
breaths/minute. The client is
manifesting shortness of
breath, bilateral 2+ pedal
edema, and an oxygen
saturation on room air of
89%. Which action should
the nurse take first?
, 4. A client with Addison's Headache and tremors
crisis is admitted for Irregular heart rate
treatment with adrenal pallor and diaphoresis
cortical supplementation.
Based on the client's
admitting diagnosis, which
findings require immediate
action by the nurse? (Select
all that apply)
5. An older client is d. Skin tenting occurs when the client's forearm is
admitted with fluid volume pinched.
deficit and dehydration.
Which assessment finding is
the best indicator of
hydration that the nurse
should report to the
healthcare provider?
6. After an inservice about a. File a detailed incident report with the specific hiring
electronic health record facility.
(EHR) security and
safeguarding client
information, the nurse
observes a colleague going
home with printed copies
of client information in a
uniform pocket. Which
action should the nurse
take?
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