Med Surg 2 Proctored Exam

The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? Select all that apply

The client with a history of alcohol use is admitted to the hospital. Upon arrival anxiety, sweating, and tremors were noted. Now, disorientation, hallucination, and hyper-reactivity are observed. The

A nurse on the general medical-surgical unit is caring for a client in shock and assesses the following: Respiratory rate: 10 breaths/min Pulse: 136 beats/min Blood pressure: 92/78 mm Hg Level of cons

The nurse is assessing a client who sustained a blunt chest injury. Which would indicate to the nurse that the client is exhibiting a flail chest?

The doctor orders your patient to start an IV Heparin drip at 16 units/kg/hr and to administer a loading bolus dose of 60 units/kg IV before initiation of the drip. You're supplied with a Heparin bag

An adult patient is admitted to the ICU with Acute Respiratory Distress Syndrome (ARDS). The patient has been intubated and is mechanically ventilated. The patient is becoming increasingly agitated, a

The emergency room nurse is caring for a client admitted from the penitentiary. What concepts will the nurse prioritize? Select all that apply

A nurse is caring for a patient receiving oxygen therapy via a nasal cannula at a flow rate of 3 liters per minute (LPM). The patient has chronic obstructive pulmonary disease (COPD) and is experienci

The ICU nurse receives report on a new client being admitted with a neck injury he received while diving into a lake. The ED nurse reports that his temp is 98.2, blood pressure is 85/54, heart rate is

A patient who has been involved in a motor vehicle crash is admitted to the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which of these prescribed interventions shou

After assessing four clients, which will the triage nurse identify to be seen first in the ED?

What is the nurse's priority action for the unconscious patient who is breathing who has been brought to the ED?

When caring for four clients, which does the nurse identify as at the highest risk for frostbite?

In addition to calling 911, what is the appropriate nursing response when a client calls the telehealth nurse to report being bitten on the arm by an unknown type of snake?

After a mass casualty event, which client will the nurse triage with a yellow tag? 1.25 Points

The SpO2 of a client receiving oxygen therapy by nasal cannula at 6 L/min has dropped from 94% an hour ago to 90%. Which action does the nurse perform first to improve gas exchange before reporting th

Which assessment finding for a client receiving oxygen therapy with a nonrebreather mask requires the nurse to intervene immediately?

A client with COPD has all of the following ABG changes from earlier today. Which change alerts the nurse to take immediate action to prevent harm?

The nurse is caring for a client with hypovolemic shock. Which new assessment finding indicates to the nurse that interventions are currently effective?

A client who has been mechanically ventilated for 5 days following ARDS is being evaluated for weaning readiness. The respiratory therapist reports the following parameters: Rapid shallow breathing in

Case study 71-73 A client was admitted with a diagnosis of respiratory failure 3 weeks ago. She required an artificial airway (tracheostomy) to help clear secretions. The previous shift nurse reports

Based on the client's vital signs, what is the appropriate nursing action?

As the assessment is completed, the nurse observes that the client has a large amount of thick secretions visible in the trach. What is the priority nursing action?

After morning care, the nurse prepares for tracheostomy care. Which action will the nurse take? Select all that apply.

Exhibits In what order will the nurse implement these interventions?