A client with a history of a bilateral adrenalectomy is admitted with a weak, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse?

An older adult client is having photocoagulation for macular degeneration. Which intervention should the nurse implement during the postprocedure care in the outpatient surgical unit?

In determining the one minute Apgar score of a neonate, the nurse assesses a heart rate of 120 beats per minute and 44 respirations per minute. The neonate has flaccid muscle tone with slight flexion and slight resistance to straightening, a loud cry with stimulation, and acrocyanotic color. Which is the correct Apgar score for this neonate?

The nurse assisting the healthcare provider with a wound debridement at the bedside of a client who is mildly confused. The client is draped and a sterile field is created. Which nursing intervention should the nurse implement for client safety?

An older adult client with Type 2 diabetes reports experiencing leg pain when walking short distances, and that the pain is relieved by rest. Which client behavior indicates an understanding of healthcare teaching to promote more effective arterial circulation?

A client receives a prescription for 1 L of lactated Ringer's IV to be infused over 12 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

A toddler is brought to the emergency department after ingesting several tablets of acetaminophen from a bottle that the toddler found in the mother's purse. The healthcare provider prescribes N-acetylcysteine solution for oral administration. Which action should the nurse implement if the child vomits?

The nurse assumes care of a postoperative adult client with type 2 diabetes mellitus and learns that the client has a current blood glucose level of 750 mg/dL (42 mmol/L). When assessing the client, which is the priority?
Reference Range: Glucose [Reference Range:74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

Patient Data

The client is ready for transfer to the neurological intensive care unit (ICU). The receiving nurse obtains report from the emergency department (ED) nurse.

Received a computed tomography (CT) scan of the head 18 gauge peripheral IV (PIV) in bilateral antecubital spaces

CMP, WBC, APTT, PT/INR drawn and results are all WNL

12-Lead ECG normal sinus rhythm (NSR)

0.9% sodium chloride infusing at 50mL/hour

Sitting in a semi Fowler's position

Client is NPO

Pharmacy bringing tissue plasminogen activator (tPA) to the unit shortly

Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided.

During tPA administration, the nurse should prioritize

The nurse evaluates the client's findings and test results. Choose the most likely options for the information missing from the statements by selecting from the lists of options provided.

The nurse recognizes that the client is most at risk for aneurysm

A client with a history of a bilateral adrenalectomy is admitted with a weak, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse?