A nurse is assisting in the care of a client who has developed cardiogenic shock.

Which pulse site should the nurse use when assessing circulation to the client’s brain?

A nurse is attending to a client who has suffered a basal skull fracture.

During the morning hygiene care, the nurse observes a thin clear drainage coming from the client’s right nostril.

What should be the nurse’s immediate action?

A nurse is assisting a postoperative client.

The client is alert and oriented to person, place, and time, and reports incisional pain of 9 on a scale of 1 to 10. Morphine 8 mg was administered subcutaneously as prescribed at 0900.

The client is now sleeping and is difficult to arouse.

Pupils are 3 mm, equal and reactive to light.

Temperature is 37.5 C (99.5°), respirations are 10/min, and pulse oximetry is 87% on room air.

Which documentation in the client’s medical record requires further action by the nurse?

A nurse is caring for a patient admitted with a lower respiratory infection.

After assisting the patient to bed and applying the prescribed oxygen, which finding would help the nurse evaluate the effectiveness of the nursing care?

Following an explosion at a local chemical lab, several people have sustained burns and are now in the triage area.

Which patient should be attended to first?

A nurse is helping a postoperative patient following a total hip arthroplasty into a supine position.

Which of the following actions is appropriate to prevent hip dislocation?

A nurse is assisting with the care of a client.

• At 1600, the nurse administered an antibiotic as prescribed.
• At 1630, the nurse noted that the client’s bilateral breath sounds were clear and present throughout.
• The client reports itching on the chest and has urticaria over the chest and trunk.
• The client states they are having difficulty swallowing and feel as if there is a lump in their throat.
• The nurse hears bilateral breath sounds with scattered wheezing throughout.

What should the nurse do next?

A nurse is educating a client newly diagnosed with hepatitis C. Which statement from the nurse best describes how the virus is transmitted?

A patient with acute pancreatitis is in severe pain.

Which position should the nurse suggest the patient to assume?

A nurse is caring for a patient diagnosed with Hodgkin disease who has significant cervical lymph node enlargement.

Which symptom should the nurse address first?

A client with a spinal cord injury is at risk for experiencing autonomic dysreflexia.

Which of the following manifestations should the nurse carefully monitor the client for?