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HESI RN Med Surg 3 Questions

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Question 1 of 5

A client is admitted to the intensive care unit (ICU) after a colon resection with the formation of a loop colostomy. The nurse determines the client's abdominal dressing is clean and dry. Vital signs are temperature 100° F (37.8° C) orally, heart rate 132 beats/minute, blood pressure 88/65 mm Hg, and urine output 10 mL/hour. Which intervention should the nurse implement?

Correct Answer: C

Rationale: The client has tachycardia, hypotension, and oliguria, suggesting hypovolemic shock. A fluid bolus is the first-line treatment to restore intravascular volume, improve blood pressure, and increase urine output.

Question 2 of 5

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Question 3 of 5

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Question 4 of 5

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Question 5 of 5

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Similar Questions

The vital signs for a client with heart failure (HF), who is admitted to the intensive care unit (ICU), are a temperature of 98.6° F (37°C), heart rate 125 beats/minute, respirations 22 breaths/minute, and blood pressure 140/50 mm Hg. The nurse determines the client's central venous pressure (CVP) and pulmonary artery wedge pressure (PAWP) are elevated. Which intervention should the nurse implement?
Based on the ABG values, the nurse knows that the client has [condition] related to [cause].
After an endotracheal tube (ETT) is initially placed for a client requiring mechanical ventilation, which intervention should the nurse implement first?
Based on the client's diagnosis, which results does the nurse expect in the blood gas? Select all that apply.
The nurse assesses the telemetry monitor of a client who is 24 hours postoperative from having a permanent pacemaker insertion. The nurse observes that a pacemaker spike is present before each QRS complex in lead II of the electrocardiogram (ECG). Which intervention should the nurse implement?

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