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?

The nurse identifies an electrolyte imbalance, elevated blood pressure, and a weight gain of 4.4 lbs (2 kg) in 24 hours in a client with hepatic failure.
Which intervention should the nurse include in the plan of care?

Upon entering a patient’s room to administer an IV antibiotic at 0900, the nurse discovers that the patient is engaged in sexual activity with a visitor.
What should be the nurse’s course of action?

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 client with a history of heart failure arrives at the emergency department describing an onset of fatigue and weakness.

The client has been taking spironolactone 50 mg tablets PO every day.

The nurse receives a report from the lab that the client has a serum potassium level of 6.2 mEq/L (6.2 mmol/L). Which intervention is most important for the nurse to implement?

A 35-year-old woman, who works as a legal secretary, visits the outpatient clinic for an assessment of consistent pain in her hands.

She reports that the pain is identical in both hands and wrists but is worse upon waking. The pain and stiffness have persisted for the past 3 months.

She believes she has arthritis because her mother and grandmother both have arthritis.

Based on the data provided, determine the most likely condition the client is experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Which intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an intravenous (IV) site in the client’s arm?

A client with a right hemopneumothorax has a chest tube connected to suction.
While turning to the left side, the client becomes suddenly short of breath and anxious. What should the nurse do next?

Which laboratory test results should the nurse monitor in a patient who has end-stage renal disease (ESRD)?

The nurse is caring for a client with a history of coronary artery disease who reports waking up with a sudden onset of vise-like chest pressure.

The client reports that the pain decreases at rest but continues to feel a constant mid-chest pressure. What intervention should the nurse perform in the immediate management of the client?

What intervention should the nurse perform in the immediate management of the client?

Which assessment finding is most crucial when planning to provide a complete bed bath to a bedfast client?