Case 4/6

Exhibits

What intervention(s) should the nurse initate if elder mistreatment is suspected? Select all that apply.

The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond?

The nurse is preparing to administer a narcotic analgesic to a client with a fractured femur who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement?

The nurse observes erythema under the chin of a client receiving oxygen at 2 L/minute per nasal cannula. Which intervention should the nurse implement?

The nurse observes a client with amyotrophic lateral sclerosis (ALS) is excessively drooling and prepares to suction the client's oral cavity. Which action should the nurse include?

A client on the cardiac telemetry unit unexpectedly begins manifesting ventricular fibrillation and the advanced cardiac life support (ACLS) team defibrillates the client, restoring a normal sinus rhythm. Later in the day, a family member questions why the code was called, telling the nurse that the client has a living will. How should the nurse respond?

The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. Which action should the nurse implement immediately?

A client is brought to the emergency department after falling from a ladder and is showing signs of confusion and disorientation. The spouse states the client appeared to have lost consciousness. The nurse is provided with a list of current medications and healthcare power of attorney. When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?

The nurse is caring for a client with decompensated liver disease who is experiencing fever, chills, and abdominal tenderness. Following a paracentesis, the nurse receives laboratory results of the ascitic fluid that show the polymorphonuclear leukocyte count is 425/mm³ (0.42 x 10⁹/L). After notifying the healthcare provider, which action should the nurse take next?

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 purulent discharge from a venous ulcer that has been unsuccessfully treated with intravenous vancomycin has been admitted with a possible vancomycin-resistant enterococci (VRE) infection. What nursing intervention(s) should the nurse include in the plan of care? Select all that apply.