A client with a deep vein thrombosis (DVT) in the left leg is on a heparin protocol. What is the most crucial intervention for the nurse to include in this client’s care plan?

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 older adult patient arrives at the clinic reporting decreased strength in knees and handgrips. What action should the nurse include in a functional assessment of this patient?

A client with a history of adrenal insufficiency is admitted to the intensive care unit with an acute adrenal crisis. The client is complaining of nausea and joint pain.
Vital signs are: temperature 102° F (38.9° C), heart rate 138 beats/minute, blood pressure 80/60 mm Hg. Which intervention should the nurse implement first?

The nurse is preparing a 50 mL dose of 50% dextrose IV for a patient with insulin shock. What is the appropriate method for administering the medication?

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 patient is a 75-year-old female who has been admitted to the preoperative area in preparation for pacemaker insertion.

She reports that she is undergoing this procedure because her heart rate has been consistently low, she feels constantly fatigued, and she has experienced one episode of fainting due to a low heart rate.

The patient has a history of progressively worsening symptomatic bradycardia and a history of atrial fibrillation, which is controlled by medication.

She has been off anticoagulants for four days in preparation for the procedure.

As the nurse prepares the patient’s plan of care, which four findings would indicate that it would be safe to administer the antibiotic vancomycin?

A primary caregiver of an older adult client calls the nurse at the outpatient clinic due to a sudden onset of changes in the client’s behavior.

The caregiver reports to the nurse that the client normally is oriented and able to answer Questions but now is confused.

What action(s) should the nurse take? Select all that apply.

A school-aged patient was recently diagnosed with type I diabetes mellitus. What symptom did the patient’s parents most likely report?

A nurse notices clear fluid on the surgical dressing of a patient who has just returned from lumbar spinal surgery. What should be the nurse’s immediate course of action?

A client with gout in the left great toe has received a prescription for prednisone 30 mg by mouth to be administered each day.
Which symptom is most important for the client to report to the healthcare provider?