The nurse enters a client's room to administer oral medications and finds an unlicensed assistive personnel (UAP) providing personal care to the client, whose condition has obviously deteriorated. The client is lying in a supine position and is weak, pale, and diaphoretic. Which is the priority nursing action?

The nurse is triaging several children as they present to the emergency room after a school bus accident. Which child requires the most immediate intervention by the nurse?

Drag from the options to complete the sentence

After listening to the client's symptoms, the nurse realizes that she likely has

Options for 1

(separation anxiety, acute stress disorder, phobia, hallucinations)

Options for 2

(undiagnosed mental health disorder, traumatic stress exposure, side effects of medication, overstimulation)

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having had prior sexually transmitted infections. Which response should the nurse provide?

A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, "Kill, kill." Which question should the nurse ask the client next?

A client with leukemia who is receiving myelosuppressive chemotherapy has a platelet count of 25,000/mm3 (25 x 109/L). Which intervention is most important for the nurse to include in this client's plan of care?

Reference Range:

Platelet Count [150,000 to 400,000/mm3 (156 400 x 109/L)]

The practical nurse (PN) reports that a client who has a fingerstick glucose of 35 mg/dL (1.94 mmol/L) is alert and diaphoretic. Which action should the charge nurse take?

Reference Ranges

• Glucose [Reference Range: 0 to 50 years: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

After receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse delegate to the practical nurse (PN)?

The healthcare provider prescribes 5% Dextrose Injection, USP with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care?

Reference Range

• Potassium [Reference Range: 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]
• Glucose [Reference Range: 0 to 50 years: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention(s) should the nurse include in the plan of care? (Select all that apply.)

The client is a 7-year-old with spastic cerebral palsy (CP) admitted to pre-op for heel cord lengthening. Child has cognitive and speech delays. Experiences absent seizures numerous times daily according to parent. Surgery went well for bilateral heel cords lengthening. The nurse is updating the plan of care.

Select 5 findings that would require immediate action prior to the nurse administering this pain medication