A 49-year-old male patient has been experiencing flu-like symptoms, including fever and chest congestion, for the past four days.

He visited the emergency department (ED) last night due to increased difficulty in breathing.

The patient has a 20-year history of smoking half a pack of cigarettes per day and has no significant medical or surgical history.

The nurse has placed the patient on a cardiorespiratory monitor and administered a nasal cannula. After completing an assessment, the nurse documented the findings in the patient’s chart.

Which assessment findings indicate hypoxia?

The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours.
Which additional action should the nurse instruct the UAP to take each time the client is turned?

An unlicensed assistive personnel (UAP) reports that a client’s right hand and fingers spasm when taking the blood pressure using the same arm.
After confirming the presence of the spasms, which action should the nurse take?

A first-time pregnant woman at 36 weeks of gestation is admitted to the labor and delivery unit because her membranes ruptured 30 minutes ago.

The initial assessment indicates a 2 cm cervical dilation, 50% effacement, -2 station, vertex presentation, greenish- colored amniotic fluid, and contractions occurring every 3 to 5 minutes.

There is a decrease in fetal heart rate after the last four contraction peaks.

What should the nurse do first?

The nurse is preparing a dose of teriparatide for a patient.

The medication is labeled as “750 mcg/2.4 mL”. How many mL should the nurse administer to deliver a dose of 60 mcg

An elderly male patient, who has been experiencing abdominal pain, is admitted to the hospital from a long-term care facility.

He hasn’t had a bowel movement in 7 days, his abdomen is distended, and he recently vomited 150 mL of dark brown emesis.

In what order should the nurse perform the following interventions? Arrange from highest to lowest priority.

A client with diabetic ketoacidosis (DKA) is receiving an IV infusion of 0.9% sodium chloride and insulin.
Two hours later, the client’s serum laboratory results show a decrease in the serum blood glucose from 580 to 430 mg/dL (32.2 to 23.86 mmol/L). What additional laboratory result is most important for the nurse to monitor?

A nurse is attending to a patient who suddenly experiences numbness and weakness on the right side of their body, including their arm and leg.

The nurse also observes a distinct droop on the right side of the patient’s face.

After reporting these findings to the healthcare provider, the nurse receives several prescriptions for the patient, including an immediate CT scan of the head.

What should be the nurse’s first course of action?

A client is experiencing severe agitation and tremors due to withdrawal from the benzodiazepine alprazolam. What is the best initial nursing action?

The nurse is implementing the plan of care for a client.

For each body system, identify the potential nursing intervention that would be appropriate for the care of the client. Each body system may support more than one potential nursing intervention.

Each category must have at least one response option selected.

The nurse is educating a first-time pregnant woman about preeclampsia.
Which symptoms are indicators of preeclampsia and should be reported to the healthcare provider? Select all that apply.