On the third postoperative day, a client who has had a hip replacement surgery becomes anxious and diaphoretic, and begins to experience auditory hallucinations. The client denies having any pain. The client's vital signs are pulse rate 125 beats/minute, respiratory rate 36 breaths/minute, and blood pressure 166/88 mm Hg. Which nursing intervention(s) should the nurse implement? (Select all that apply.)

The nurse is preparing an older client for a magnetic resonance imaging (MRI) with contrast. Which laboratory value should the nurse report to the healthcare provider before the scan is performed?

Reference Range:
Glycosylated hemoglobin (A1C) [4% to 5.9%]
Creatinine [0.5 to 1.1 mg/dL (44 to 97 umol/L)]
Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]
Blood Urea Nitrogen (BUN) [10 to 20 mg/dL (3.6 to 7.1 mmol/L)]

While completing a health assessment for a young adult female with acute appendicitis, the client informs the nurse that there is a chance that she may be pregnant. The operating team is preparing to take the client to surgery. Which intervention should the nurse implement immediately?

An older adult client with symptoms of osteoarthritis asks the nurse which form of exercise would be most beneficial. Which is the best response by the nurse?

A client with obstructive sleep apnea (OSA) calls the clinic to report difficulty wearing the continuous positive air pressure (CPAP) mask because it is uncomfortable. The client asks the nurse for an alternative way to manage sleep apnea. Which recommendation should the nurse provide?

After teaching a client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Which food choices eliminated by the client indicate to the nurse that teaching has been successful?

A client presents with the onset of a severe headache, fever, nuchal rigidity, and a petechial rash on arms and legs. The nurse recognizes the client is exhibiting symptoms of which condition?

A 70-year-old female presents to the emergency department through triage with a noticeable facial droop and garbled speech. After having a few drinks at a local seafood restaurant, the client's husband noticed his wife's speech became difficult to understand.

Flow sheets

1915

Arrival at emergency department

1920

Vital Signs:

- Temperature: 98.2° F (36.8° C)

- Heart rate: 92 beats/minute

- Respirations: 24 breaths/minute

- Blood pressure: 210/98 mmHg

- Oxygen saturation: 95% on room air

Imaging studies

1935

Head CT scan results:

- No evidence of intracranial hemorrhage

- No evidence of acute disease

Orders

- Obtain CT scan of the head.

- Insert a large bore peripheral IV.

- Start normal saline infusion at 50 mL/hour.

• The nurse administered tPA and conducted neurologic assessments every 15 minutes during the infusion.
• The tPA infusion finished and the nurse performed neurologic assessments every 30 minutes for the 6 hours following the administration.
• The client was noted to be stable with unchanged neurologic assessments.
• The nurse begins to plan care for the client's recovery and identifies interdisciplinary team members who can assist with the client's recovery.

Select the interdisciplinary team members who should assist the client in recovery.

The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?

The nurse is caring for a client who had a cholecystectomy two days ago. The client is febrile, reporting upper abdominal pain radiating to the back and has had three episodes of vomiting in the last 8 hours. The nurse reviews the client's serum amylase and lipase level results which are twice the normal value. Based on these findings, the nurse should recognize the client is exhibiting symptoms of which condition?