Nurse plans to administer a dose of metoprolol at 0900 to a client with HTN. At 0800 nurse notes telemetry pattern shows second degree heart block with Ventricular rate of 50. Action Hold scheduled ... dose and notify HCP of telemetry pattern Nurse is reviewing client ECG and determines PR interval prolonged. Indicates Increased conduction time from the SA node to the AV junction When assessing a restless, intubated client on mechanical ventilation, nurse auscultates breath sounds on right side only. Action Reposition the depth of the ET tube Nurse called to a train derailment likely caused by terrorist bomb. Triage in order Middle-aged man wandering around Woman sitting on ground with blanket Crying child held by another passenger Mother and father just arrived on scene Client with pneumonia admitted with severe SOB, ABGs pH 7.30, PaO2 60, PaCO2 62, HCO3 35. Which needs immediate communication to HCP Drowsiness and diff in arousing Assess a 78 year old with L sided HF. Symptoms Dyspnea, cough, fatigue Caring for a burn patient with serum potassium of 4. Question which medication Potassium Patient admitted with deep 2 nd degree burns of thighs, chest and arms covering 40% BSA. Fluid shift after burn so nurse expects Decreased cardiac output Patient bedridden for 2 wks with following lab values: pH 7.37, PO2 90, PCO2 40, HCO3 25, hypoalbuminemia and hypocalcemia. Priority action Turn patient side to side q2h Which age group should nurse assess first 40 year old with sickle cell crisis There has been a major disaster. Triage nurse should give which patient priority Cut over eye Move which patient to medical surgical unit Patient with ABNL liver levels One open bed in ICU but reserved for patient coming from PACU with respiratory problems, what to do Take patient to I.......................................................................CONTINUED [Show More]
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