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CASE STUDY QUESTION The following questions pertain to the client who is newly admitted in the ICU with diabetic ketoacidosis.   QUESTION: The nurse knows that the presence of ketones in the blood in this client is the result of which of the following?

The nurse is caring for the client with cerebral edema with a Glasgow Coma Scale (GCS) of 5 and an intracerebral pressure reading (ICP) of 21 mm/Hg. Which of the following medications ordered by the healthcare provider would be inappropriate to administer to the client?

An acutely ill client is being cared for in the critical care unit. The client is delirious and is exhibiting signs of significant anxiety. The nurse should recognize that the client is at greatest risk for which of the following nursing diagnosis?

The client is diagnosed with mitral stenosis and new-onset atrial fibrillation. Which of the following interventions could the nurse delegate to the unlicensed assistive personnel? Select all that apply.

The nurse is caring for a spinal cord injury client in neurogenic shock. Several liters of IV fluids have been administered without improvement of the patient’s condition. Current vital signs assessed by the nurse include: B/P 60/40 mmHg, Pulse 132 beats/min, RR 28 breaths/min, and rectal temperature of 35.5°C. Which of the following provider orders should the nurse perform first?

The nurse is caring for the client admitted with new onset of slurred speech, facial droop, and left-sided weakness that started 3 hours ago. The CT scan has ruled out the presence of an intracranial bleed. Which of the following actions are most important to include in the client’s plan of care? Select all that apply.

CASE STUDY QUESTION The following questions pertain to the client who is newly admitted in the ICU with diabetic ketoacidosis.   QUESTION: The nurse knows that the presence of ketones in the blood in this client is the result of which of the following?

Daily weights are being recorded for an acute renal failure client who has a urine output less than the total intake of IV fluids and oral intake. The client’s weight was 97.5 kg yesterday and today’s weight is 99 kg. Which of the following would be a priority intervention for this client?

The nurse is caring for a spinal cord injury client in neurogenic shock. Several liters of IV fluids have been administered without improvement of the patient’s condition. Current vital signs assessed by the nurse include: B/P 60/40 mmHg, Pulse 132 beats/min, RR 28 breaths/min, and rectal temperature of 35.5°C. Which of the following provider orders should the nurse perform first?

The nurse is caring for a client with a left sided chest tube that is experiencing manifestations of a tension pneumothorax. The nurse knows that a client with a chest tube is at risk for tension pneumothorax if which of the following scenarios is present?