The nurse identifies several nursing problems for an older adult client with gastroenteritis who is experiencing fever, chills, anorexia, and diarrhea.
The client has a history of a stroke with left-sided hemiplegia and is dependent on care provided by the spouse. Which problem should the nurse determine has the highest priority?

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?

The nurse is developing the plan of care for a client diagnosed with Cushing’s syndrome and identifies that the client’s risk factors include poor wound healing, decreased bone density, and increased capillary fragility.
Which outcome statement should the nurse include in the plan of care?

An unlicensed assistive personnel (UAP) reports that a client’s right hand and fingers spasm when taking the blood pressure using the same arm.
After confirming the presence of the spasms, which action should the nurse take?

A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line.

The abdominal dressing is no longer occlusive, and the IV insertion site is pink.

What intervention should the nurse implement?

A client with a right hemopneumothorax has a chest tube connected to suction.
While turning to the left side, the client becomes suddenly short of breath and anxious. What should the nurse do next?

An elderly male patient, who has been experiencing abdominal pain, is admitted to the hospital from a long-term care facility.

He hasn’t had a bowel movement in 7 days, his abdomen is distended, and he recently vomited 150 mL of dark brown emesis.

In what order should the nurse perform the following interventions? Arrange from highest to lowest priority.

An adolescent patient with a non-union of a comminuted fracture of the tibia is admitted with osteomyelitis.
After the healthcare provider collects bone aspirate specimens for culture and sensitivity and applies a cast to the adolescent’s lower leg, what should the nurse do next?

A 49-year-old male patient has been experiencing flu-like symptoms, including fever and chest congestion, for the past four days.

He visited the emergency department (ED) last night due to increased difficulty in breathing.

The patient has a 20-year history of smoking half a pack of cigarettes per day and has no significant medical or surgical history.

The nurse has placed the patient on a cardiorespiratory monitor and administered a nasal cannula. After completing an assessment, the nurse documented the findings in the patient’s chart.

Which assessment findings indicate hypoxia?

A client with chronic obstructive pulmonary disease (COPD) receives a prescription for chest physiotherapy (CPT) to help mobilize secretions.
Following the therapy, which finding indicates to the nurse that the intervention was effective?

A client with end-stage Alzheimer’s disease is brought to the clinic by the caregiver for an appointment with the healthcare provider.

The caregiver speaks privately to the nurse about not sleeping well at night and experiencing frequent periods of crying.

Which intervention should the nurse implement?