A client is admitted to the surgical intensive care unit following the removal of a large portion of the intestines due to a gunshot wound to the abdomen. The client begins to display signs of septic shock and a sepsis protocol is initiated. Which intervention is most important for the nurse to include in the plan of care?

Which instruction regarding skin care should the nurse provide to a client who is receiving radiation therapy for metastatic breast cancer?

The nurse is caring for a client with pulmonary edema who is short of breath and coughing pink tinged sputum. Which position should the nurse place the client to ease respiratory distress?

A client who is having gastrointestinal (GI) difficulties is undergoing diagnostic procedures.

The client asks the nurse about the difference between ulcerative colitis and Crohn's disease.

Which information should the nurse offer?

When assessing a newborn girl with salt-wasting congenital adrenal hyperplasia due to 21 hydroxylase deficiency, the nurse notes that the infant has an enlarged clitoris. Which intervention should the nurse implement?

An unlicensed assistive personnel (UAP) is assigned to a client with flu-like symptoms who has been placed on droplet precautions. The UAP requests a change in assignment, stating she has not yet been fitted for a particulate filter mask. Which action should the nurse take?

The nurse is triaging several children as they present to the emergency room after a school bus accident. Which child requires the most immediate intervention by the nurse?

The healthcare provider prescribes 5% Dextrose Injection, USP with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care?

Reference Range

• Potassium [Reference Range: 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]
• Glucose [Reference Range: 0 to 50 years: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

Following morning care, a client with a C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implementfirst?

A client with persistent low back pain has received a prescription for an electronic stimulator (TENS) unit. After the nurse applies the electrodes and turns on the power, the client reports feeling a tingling sensation. How should the nurse respond?

The client is a 32-year-old multigravida at 28 weeks' gestation, who presents to the obstetrician's office for a routine prenatal visit. Obstetrical history reveals she has given birth three times; once at 35 weeks (twins), once at 38 weeks (singleton) and once at 41 weeks (singleton). All of these children are alive and well. She had one spontaneous abortion at 10 weeks' gestation. Her fourth child weighed 9 pounds (4.08 kg) at 41 weeks gestation.

The nurse is reviewing nurses' notes to determine if there are any variations.

Click to highlight the findings that would indicate the client has developed a complication related to pregnancy.

Client is at 28 weeks. She has been receiving prenatal care since 8 weeks' gestation. Her fasting 1-hour glucose screening level, which was done 1 week prior, is 164 mg/dl. (9.1 mmol/L) Her 3-hour oral glucose tolerance test results reveal a fasting blood sugar of 168 (9.3 mmol/L) and a two-hour postprandial of 220 mg/dL (12.2 mmol/L).