The nurse is rounding on a patient diagnosed with heart failure (HF). The patient is receiving 1 liter of 0.9% sodium chloride at 150 ml/hr with two hours left on the infusion. The nurse observes that the patient has a moist cough, distended neck veins, and dyspnea. What actions should the nurse take? Select all that apply by choosing the three highest priority nursing actions for this patient.

The nurse is caring for a patient with a chest tube that is connected to a water seal drainage system. The nurse observes the chest tube is disconnected from the chest tube drainage system. Which of the following actions should the nurse take first?

When entering the room of a patient who has a chest tube attached to a water-seal drainage system, the nurse observes the chest tube is lying on the floor. Which of the following actions should the nurse take first?

The nurse is caring for a patient on mechanical ventilation. Which of the following must the nurse implement to prevent ventilator-associated pneumonia (VAP)? Drag and Drop Directions: Click and drag the correct answer choices from the Possible Answers box on the left to the Correct Answers box on the right. More than one answer may be chosen.

A patient has returned to the cardiac step-down unit following a percutaneous intervention (PCI). The nurse observes that the patient has bleeding at the right-sided femoral sheath site. What is the nurses' first action?

An ICU nurse is at the nurse's station when they suddenly hear their patient's ventilator alarming. Which actions should the nurse take when responding to ventilator alarms? Select all that apply.

A patient is hospitalized with a second episode of pulmonary embolism (PE) despite anticoagulation therapy. What is the nurse's best action?

A nurse provides care to a client with COPD, what symptoms does the nurse anticipate? Directions for drag and drop: Click and drag the possible answers from the left box to the right to indicate your answers.

A nurse is planning care for a patient with a flail chest. Which of the following interventions are appropriate for this patient? Select all that apply. Directions for Drag and Drop: Click and drag the correct possible answers from the left box to the right to indicate your answer.

A nurse is caring for a patient with a diagnosis of myocardial infarction (MI), who reports chest pain 8/10. The nurse administers a sublingual nitroglycerin tablet as prescribed. After 5 minutes, the chest pain is 6/10. What action does the nurse take first?

A patient with a medical history of COPD is admitted with pneumonia with a right-sided pleural effusion. At 1130 the patient returns to the unit after a thoracentesis. Which assessment finding is the highest priority?

A postoperative client is receiving intravenous heparin for a pulmonary embolism. The nurse observes frank red blood in the client's foley catheter bag. Which medication will the nurse prepare to administer?

The critical care nurse is assessing a patient for readiness to be weaned from the ventilator. Which of the following indicates that the patient is most likely to have successful weaning from the ventilator?

The nurse is monitoring the central venous pressure (CVP) of a patient with heart failure. The nurse observes that the reading is 12 mmHg. What is the nurse's best action?

A nurse is caring for a patient who was admitted for COPD exacerbation. Which of the following manifestations most likely suggestive of the development of respiratory distress? Select all that apply.

The ED nurse is assessing a 48-year-old female (sex at birth) client who has a history of diabetes. Which of the following signs and symptoms would cause the nurse to expect that the client may be experiencing a myocardial infarction? Select all that apply.

The nurse is developing the plan of care to include prevention of foot drop for a patient on a mechanical ventilator who is sedated. What intervention should the nurse include in the plan of care?

The nurse assigned a patient who was diagnosed with a pulmonary embolism. Which of the following potential complication during the treatment for pulmonary embolism should the nurse monitor for?

The nurse is caring for a client who presents to the emergency department with chest pain, nausea, and diaphoresis. The client's blood pressure is 168/94. The nurse observes the following cardiac rhythm (see the 6-second rhythm strip below and in the attachment). What is the priority medication for this client?

The nurse is caring for a patient and observes the following rhythm on the monitor (see image below or in the attachment for a 6-second rhythm strip). The patient has a blood pressure of 98/56 mmHg and complains of dizziness and chest pain. What intervention should the nurse expect to implement first?

The nurse is assessing the level of sedation for a patient who is intubated and receiving mechanical ventilation. The nurse observes that the patient's RASS (see RASS tool below or in the attachment) is +2. What is the nurse's best action?

The nurse is caring for a patient and observes the following rhythm on the monitor (see image below or in the attachment for a 6-second rhythm strip). The patient is alert and oriented x3, has a blood pressure of 105/56 mmHg, and denies chest pain. What action should the nurse take first?

An ICU nurse is caring for a patient who is at risk for ICU delirium. What is the best method for the nurse to assess this patient for delirium?