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The critical are charge nurse is responsible for the care of four patients receiving mechanical ventilation. Which patient is most at risk for failure to wean and ventilator dependence? 

Which nursing concept is the priority in planning the initial emergency intervention for Ms. Nightingale ?

A patient with a pulmonary embolus is receiving anticoagulation with IV heparin. What instructions would the nurse give the assistive personnel (AP) who will help the patient with activities of daily living?

Use the following Case Study to answer the next question: Ms. Atlantic is a 64 year old Hispanic woman who is being admitted directly to the medical unit after visiting her health care provider (HCP) because of shortness of breath and increased swelling in her ankles and calves.  She is being admitted with a diagnosis of chronic kidney failure (CKD). Ms. Atlantic states that her symptoms have become worse over the past 2 to 3 months and that she uses the bathroom less often and urinates in small amounts.  Her medical history includes hypertension (30 years), coronary artery disease (18 years), type 2 diabetes (14 years), and appendectomy at age 29, cataract surgery to the left eye 3 years ago and right eye 2 years ago, and three pregnancies with healthy births.  She also has gastroesophageal reflux disease (GERD), which is controlled with over the counter (OTC) famotidine 20 mg as needed.  Ms. Atlantic vital signs values on admission were as follows:  Blood pressure                                 163/95 mm/Hg Heart rate                                             87 beats/min O2 saturation                                        89% on room air Respiratory rate                                     29 breaths/min Temperature                                            97.8 F (36.6C) The patient is to be placed on oxygen at 2 L/min via nasal cannula. Admission laboratory tests for which patient samples are to e collected on the unit include serum electrolyte levels, kidney function test, complete blood count, and urinalysis. A 24 hour urine collection for the determination of creatinine clearance has been ordered.   

A client diagnosed with cardiomyopathy is hyponatremic as a result of fluid volume overload.  A fluid restriction of 800 ml/24 hours is ordered by a physician.  Which action by the nurse is most appropriate? 

The nurse is caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. To prevent ventilator associated pneumonia (VAP), which action is most important to include the plan of care? 

After the respiratory therapist performs suctioning on a patient who is intubated, the assistive personnel (AP) measures vital signs for the patient.  Which vital sign value should the AP be instructed to report the registered nurse (RN) immediately? 

Which nursing assessment is most accurate in determining the patency of a patient’s newly placed left forearm internal arteriovenous (AV) fistula for hemodialysis?

A nurse is caring for a patient with chronic renal failure.  The laboratory results indicate hypoglycemia and hyperphosphatemia.  When assessing the patient, the registered nurse should be alert for which  of the following? Select all that apply.

The nurse is admitting a patient for whom a diagnosis of pulmonary embolus (PE) must be ruled out. The patient’s history and assessment reveal all of these findings, Which finding supports the diagnosis of PE?