1. A male client with stomach cancer returns to the unit following a total gastrectomy. He has a

nasogastric tube to suction and is receiving Lactated Ringer’s solution at 75 mL/hour IV. One

hour after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the

client’s heart rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to

reporting the finding to the surgeon. Which action should the nurse implement first?

a. Measure and document the client’s urinary output.

b. Request the client’s reserved unit if packed red blood cells.

c. Prepare the placement of a central venous catheter.

d. Increase the infusion rate of Lactated Ringer’s solution.

2. an adult male who fell 20 feet from the roof of this home has multiple injuries, including a right

pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to

the intensive care unit (ICU). the nurse notes that the suction control chamber is bubbling at the

- 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml of bright red

blood is measured in the collection chamber. Which intervention should the nurse implement?

a. Add sterile water to the suction control chamber.

b. Give blood from the collection chamber as autotransfusion

c. Manipulate blood in tubing to drain into chamber.

d. Increase wall suction to eliminate fluctuation in waterseal.

3. A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100

mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is

manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room air

of 89%. Which action should the nurse take first?

a. Elevate the foot of the bed.

b. Restrict the client’s fluid.

c. Begin supplemental oxygen.

d. Prepare the client for hemodialysis.