A patient admitted with acute renal failure asks for pain medication for a headache described as five out of ten on the pain scale. The nurse checks the MAR and sees that the only pain medication ordered is Ibuprofen. Which of the following actions should the nurse take first to ensure patient safety?

Patient Profile:

• Age: 68 years
• Gender: Male
• Medical History: Hypertension, Type 2 Diabetes Mellitus
• Medications: Lisinopril, Metformin
• Allergies: None

Chief Complaint: The patient presents to the emergency department (ED) with sudden onset of right-sided weakness and difficulty speaking that began approximately 1 hour prior to arrival.

Choose three parameters the nurse should monitor to assess the patient's progress.

Patient Profile:

• Age: 68 years
• Gender: Male
• Medical History: Hypertension, Type 2 Diabetes Mellitus
• Medications: Lisinopril, Metformin
• Allergies: None

Chief Complaint: The patient presents to the emergency department (ED) with sudden onset of right-sided weakness and difficulty speaking that began approximately 1 hour prior to arrival.

Choose two actions the nurse should take to address the condition identified in the previous question.

Patient Profile:

• Age: 68 years
• Gender: Male
• Medical History: Hypertension, Type 2 Diabetes Mellitus
• Medications: Lisinopril, Metformin
• Allergies: None

Chief Complaint: The patient presents to the emergency department (ED) with sudden onset of right-sided weakness and difficulty speaking that began approximately 1 hour prior to arrival.

Choose two actions the nurse should take to address the condition identified in the previous question.

Patient Profile:

• Name: Sarah Johnson
• Age: 54
• Diagnosis: Metastatic breast cancer, Stage IV, diagnosed six months ago with metastasis to the liver and bone

Treatment Plan:

• Surgery: Lumpectomy with axillary lymph node dissection
• Chemotherapy: Adriamycin and Cyclophosphamide (AC) regimen
• Radiation Therapy: Targeted treatment to the chest wall post-surgery

Clinical Presentation:

Subjective Data:

• Reports of nausea and vomiting, especially after chemotherapy sessions
• Expresses feelings of sadness and fear regarding her prognosis and the impact on her family
• States she has lost 10 pounds in the last month due to decreased appetite and nausea
• Describes pain in the surgical area and generalized body pain that worsens at night
• Mentions experiencing a red, itchy rash on her chest from radiation therapy

Objective Data:

• Vital signs: HR 78 bpm, BP 120/80 mmHg, Temp 98.6°F
• Weight: 135 lbs (down from 145 lbs)
• Physical examination reveals tenderness in the left breast and axilla, and a rash in the radiation field
• Labs: Mild anemia (Hgb 10.5 g/dL), elevated liver enzymes

Nursing Diagnoses:

1. Nausea related to chemotherapy as evidenced by patient report and vomiting episodes
2. Imbalanced Nutrition: Less than Body Requirements related to nausea and weight loss as evidenced by a 10-pound weight loss and decreased appetite
3. Acute Pain related to surgical procedure and cancer

Which educational point should the nurse emphasize regarding skin care during radiation therapy? Select all that apply.