A nurse is caring for a client with Guillain-Barré syndrome who has been admitted to the intensive care unit
During the last 2 hours, the nurse notes that the client's vital capacity has declined to 12 mL/kg, and the client is having difficulty clearing secretions. What would be the nurse's best first action? A. Place the client in a high Fowler's position.
B. Prepare the client for elective intubation.
C. Administer oxygen via a nasal cannula.
D. Auscultate for breath sounds.
B
Deterioration in vital capacity to less than 15 mL/kg and the inability to clear secretions are in-dications for elective intubation.
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When the nurse observes a patient experiencing a severe episode of autonomic dysreflexia, what should be the initial intervention?
a. Locate the cause of irritation b. Assess the blood pressure c. Cover the patient with several blankets d. Raise the head of the bed to a high Fowler position
Emergency response personnel arrive at the site of a collapsed building. Some victims are walking away from the building, while others are lying on the ground around the perimeter
If implementing reverse triage, what should the emergency personnel do first? 1. Identify one safe location for all ambulatory victims to be assessed and observed. 2. Systematically assess each victim lying on the ground and assign a color. 3. Enter the building to locate other victims who might not have been able to leave before the collapse. 4. Transfer the victims on the ground to stretchers and send them to the local emergency department.
Which antiretroviral drugs have greater effectiveness when administered with ritonavir? (select all that apply)
a. Edurant (rilpivirine) b. Emtriva (emtricitabine) c. Invirase (saquinavir) d. Lexiva (fosamprenavir) e. Prezista (darunavir) f. Reyataz (atazanavir) g. Tivicay (dolutegravir) h. Ziagen (abacavir)
The school-age child will gain approximately how much weight during this phase?
1. 10 kg/year 2. 3 kg/year 3. No weight gain at this age 4. 1-2 kg/year