A patient admitted to the hospital with a suspected ruptured diverticulum develops signs and symptoms of septic shock.

The healthcare provider prescribes a sepsis protocol.

Which intervention is most important for the nurse to include in the plan of care?

A client with atrial fibrillation is scheduled for an elective cardioversion.

The nurse prepares for the procedure by inserting two intravenous (IV) catheters and connecting the monitoring lead wires to the client.
Which action is most crucial for the nurse to take before initiating the cardioversion?

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.

When formulating a nursing care plan for a client diagnosed with Parkinson’s disease, which nursing problem should be given the highest priority?

The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents.
Which information is most important for the nurse to include?

A 10-year-old child with pneumonia is receiving oxygen at 5 L/minute via a nasal cannula.
When planning care for this child, what principle of oxygen administration should the nurse keep in mind?

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?

A patient with acute renal failure (ARF) is admitted due to uncontrolled type 1 diabetes mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale.
What is the most important intervention for the nurse to include in this patient’s plan of care?

A first-time pregnant woman at 36 weeks of gestation is admitted to the labor and delivery unit because her membranes ruptured 30 minutes ago.

The initial assessment indicates a 2 cm cervical dilation, 50% effacement, -2 station, vertex presentation, greenish- colored amniotic fluid, and contractions occurring every 3 to 5 minutes.

There is a decrease in fetal heart rate after the last four contraction peaks.

What should the nurse do first?

A patient with a history of heart failure presents at the emergency department reporting fatigue and weakness. The patient has been taking 50 mg spironolactone tablets orally every day.

The nurse receives a lab report indicating the patient’s serum potassium level is 6.2 mEq/L (6.2 mmol/L). What is the most important intervention for the nurse to implement?

An adult client is admitted to the psychiatric unit due to a daily, intricate handwashing ritual that lasts two hours or more.

The client is concerned about maintaining cleanliness and refuses to sit on any chairs in the day area.

This client’s handwashing is indicative of what type of clinical behavior?