The nurse is caring for an elderly client with type II diabetes who has had nausea, vomiting and diarrhea for several days and who now is disoriented and listless. Initial vital signs: B/P 72/62, pulse 146 irregular and thready, respirations 38 breaths per minute and shallow, and temperature of 97.0 F rectally. The skin is cool and clammy. The nurse recognizes that this client's symptoms are most indicative of which stage and type of shock? The:

A patient is ordered 1 unit of packed red blood cells (250mL) to be transfused over 120 minutes. The drop factor on the tubing is 15 gtt/mL. At what rate should the nurse regulate the IV (gtt/min)? (round to the nearest whole number)

The nurse is testing the function of cranial nerve XI (Spinal accessory nerve). Which finding would the nurse expect if the nerve is intact?

The nurse is caring for a client who has suffered a gunshot wound to the anterior chest. The client has been intubated and is currently being ventilated with a bag-valve device. What is the priority intervention for this client now?

What action priority in preventing anaphylactic shock?

For the nurse to correctly classify the severity of a burn injury of a client, what must be assessed?
(Select All that Apply.)

Due to cranial nerve involvement in Bell's palsy, which of the following would prevent a potential complication from the disorder?

The nurse is caring for a client who received a blunt force injury to zone II of the neck. Which assessment finding should the nurse report to the physician IMMEDIATELY?

A patient is ordered a heparin infusion at 1200 units/hour. Historically. IV heparin is premixed as 25.000 units of heparin in 250 mL NSS at the institution. Nurse A starts the infusion at 12 m/hr at 1700. The nurse asks their colleague to cosign the infusion for a prescribed rate change at 1900. Nurse B reminds Nurse A that there has been a recent pharmacy policy change. The V heparin that the patient is currently receiving is 50.000 units in 250 mL in NSS. Which of the following action(s)/statements) are accurate in this scenario?
(Select All that Apply.)

The nurse is preparing to start a transfusion of packed red blood cells. Which IV site should the nurse use?

The nurse caring for a client with severe sepsis suspects the client may be developing disseminated intravascular coagulation (DIC). Which of the following signs and symptoms would support the diagnosis of DIC?