A 28-year-old client is brought to the emergency department after a motor vehicle accident and has suffered a fractured pelvis. They may also begin to have difficulty protecting their own airway – the provider needs to be notified. ↓ blood pressure, not responding to fluids. Which nurse should be assigned to care for an intubated client who has septic shock as the result of a methicillin-resistant Staphylococcus aureus (MRSA) infection? Nurses should assess their patients for the risk of developing hypovolemic shock. When the nurse notifies the surgeon, he directs her to continue to take the client's vital signs every 15 min and call him back in 1 hour. The nursing assistant is concerned about a postoperative client with blood pressure (BP) of 90/60 mm Hg, heart rate of 80 beats/min, and respirations of 22 breaths/min. In a patient with hypovolemic shock, it will be low (<4 mmHg).

Recite: Cover the note-taking column with a sheet of paper.

(Select all that apply. Call the health care provider. Rationale: The nurse should suggest the client eat avocados, which are an excellent dietary source of potassium A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. Burns (plasma loss due to capillary permeability). A client recovering from an open reduction of the femur suddenly feels light-headed, with increased anxiety and agitation. The patient may have lost some fluid already, or maybe they’re at risk for bleeding.

Shorter and thicker catheters will provide for faster fluid administration.
Prolonged vomiting or diarrhea.

At this rate, 1 L of fluids takes 1 hour to infuse. (Select all that apply.) For patients who have lost significant amounts of blood due to trauma or hemorrhage, they should receive transfusions of blood products. Patients whose airway has been compromised due to ↓ LOC may need to be intubated to protect their airway, and placed on a ventilator. Module 0 – Nursing Care Plans Course Introduction, 00.01 Nursing Care Plans Course Introduction, Module 1 – Understanding Nursing Care Plans, 01.03 Using Nursing Care Plans in Clinicals, Module Cardiovascular (Cardiac, CVD) Care Plans, Nursing Care Plan for Atrial Fibrillation (AFib), Nursing Care Plan for Congenital Heart Defects, Nursing Care Plan for Congestive Heart Failure (CHF), Nursing Care Plan for Gestational Hypertension, Preeclampsia, Eclampsia, Nursing Care Plan for Heart Valve Disorders, Nursing Care Plan for Myocardial Infarction (MI), Nursing Care Plan for Thrombophlebitis / Deep Vein Thrombosis (DVT), Module Eyes, Ears, Nose, Throat (EENT) Care Plans, Nursing Care Plan for Cleft Lip / Cleft Palate, Nursing Care Plan for Infective Conjunctivitis / Pink Eye, Nursing Care Plan for Otitis Media / Acute Otitis Media (AOM), Nursing Care Plan for Constipation / Encopresis, Nursing Care Plan for Diverticulosis / Diverticulitis, Nursing Care Plan for Eating Disorders (Anorexia 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Shingles, Nursing Care Plan for Lymphoma (Hodgkin’s, Non-Hodgkin’s), Nursing Care Plan for Skin cancer – Melanoma, Basal Cell Carcinoma, Squamous Cell Carcinoma, Nursing Care Plan for Varicella / Chickenpox, Nursing Care Plan for Burn Injury (First, Second, Third degree), Nursing Care Plan for Eczema (Infantile or Childhood) / Atopic Dermatitis, Nursing Care Plan for Pressure Ulcer / Decubitus Ulcer (Pressure Injury), Nursing Care Plan for Alcohol Withdrawal Syndrome / Delirium Tremens, Nursing Care Plan for Alzheimer’s Disease, Nursing Care Plan for Autism Spectrum Disorder, Nursing Care Plan for Dissociative Disorders, Nursing Care Plan for Generalized Anxiety Disorder, Nursing Care Plan for Mood Disorders (Major Depressive Disorder, Bipolar Disorder), Nursing Care Plan for Personality Disorders, Nursing Care Plan for Post-Traumatic Stress Disorder (PTSD), Nursing Care Plan for Somatic Symptom Disorder (SSD), Nursing Care Plan for Suicidal Behavior Disorder, Nursing Care Plan for Addison’s Disease (Primary Adrenal Insufficiency), Nursing Care Plan for Diabetic Ketoacidosis (DKA), Nursing Care Plan for Diabetes Mellitus (DM), Nursing Care Plan for Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS), Nursing Care Plan for Myasthenia Gravis (MG), Nursing Care Plan for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), Nursing Care Plan for Systemic Lupus Erythematosus (SLE), Nursing Care Plan for Cerebral Palsy (CP), Nursing Care Plan for Increased Intracranial Pressure (ICP), Nursing Care Plan for Multiple Sclerosis (MS), Nursing Care Plan for Neural Tube Defect, Spina Bifida, Nursing Care Plan for Parkinson’s Disease, Module Obstetrics (OB) & Pediatrics (Peds) Care Plans, Nursing Care Plan for Abortion, Spontaneous Abortion, Miscarriage, Nursing Care Plan for Abruptio Placentae / Placental abruption, Nursing Care Plan for Bronchiolitis / Respiratory Syncytial Virus (RSV), Nursing Care Plan for Fetal Alcohol Syndrome (FAS), Nursing Care Plan for Hyperbilirubinemia of the Newborn / Infant Jaundice / Neonatal Hyperbilirubinemia, Nursing Care Plan for Meconium Aspiration, Nursing Care Plan for Pediculosis Capitis / Head Lice, Nursing Care Plan for Premature Rupture of Membranes (PROM) / Preterm Premature Rupture of Membranes (PPROM), Nursing Care Plan for Phenylketonuria (PKU), Nursing Care Plan for Postpartum Hemorrhage (PPH), Nursing Care Plan for Preterm Labor / Premature Labor, Nursing Care Plan for Acute Respiratory Distress Syndrome, Nursing Care Plan for Asthma / Childhood Asthma, Nursing Care Plan for Bronchoscopy (Procedure), Nursing Care Plan for Chronic Obstructive Pulmonary Disease (COPD), Nursing Care Plan for Pertussis / Whooping Cough, Nursing Care Plan for Pneumothorax/Hemothorax, Nursing Care Plan for Respiratory Failure, Nursing Care Plan for Restrictive Lung Diseases, Nursing Care Plan for Thoracentesis (Procedure), Module Sepsis (Septic) & Shock Care Plans, Module Musculoskeletal and Skeletal (Osteo) (Bones) Care Plans, Nursing Care Plan for Gout / Gouty Arthritis, Nursing Care Plan for Rheumatoid Arthritis (RA). What typical sign/symptom indicates the early stage of septic shock? The nurse notifies the surgeon, who tells the nurse to continue to measure the clients vital signs every 15 minutes and to report back in one hour.

From a legal perspective, which of the following actions should the nurse take next?
During the massive transfusion protocol, units of plasma, platelets, and clotting factors are given at certain intervals to prevent this clotting problem. Remove all personal clothes, jewelry, etc. Massive Transfusion Protocol – used to prevent clotting problems when patients receive multiple units of blood. Either way, the more aware the nurse is of the risk, the more likely it can be prevented or caught early. Remain with the client. Hemodynamic measurements will tell us the severity of the shock and how well the patient is responding to treatment. When the nurse notifies the surgeon, he directs her to continue to measure the client's vitals every 15 minute and call him back in 1 hour. This should be done with a pressure bag or rapid infuser.


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