The nurse reviews the information from the initial assessment and history and physical.
Which 6 findings in the client's history should the nurse recognize as risk factors for a cerebrovascular event?

The healthcare provider prescribes dalteparin 200 units/kg subcutaneously once day for a client who weighs 154 pounds. The medication is available in 25,000 units/mL vial. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

The nurse notes that a client with depression has been more withdrawn and non communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

An older adult client is being discharged after implantation of a permanent pacemaker. The client should be instructed to avoid which item?

Which long-term outcome is most important for the nurse to include in the plan of care for an older adult client with chronic pyelonephritis?

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to an unlicensed assistive personnel (UAP)?

When preparing to administer an intravenous medication through a client's triple lumen central venous catheter, the nurse observes that there are no continuous intravenous fluids infusing. Which action should the nurse take?

Patient Data

• Heart rate 88 beats/minute
• Blood pressure 122/72 mm Hg
• Temperature 100.5° F (38° C)
• Reports of pain with ambulation
• Respirations 20 breaths/minute
• Left lower leg with erythema, warm, and swollen
• Blood glucose 252 mg/dL (13.9 mmol/L)
• Capillary refill greater than 3 seconds bilateral lower extremities
• Pain: 2 on a 0 to 10 pain scale, bilateral lower legs described from neuropathy
• Body circumference: Right calf 16.5 in (41.9 cm); left calf 17.25 in (43.8 cm)

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? Select all that apply.

A client who recently experienced a myocardial infarction has decreased cardiac output and prolonged capillary refill. Which finding should the nurse recognize as compensatory response to decreased cardiac output and circulatory volume?

A client is admitted to the surgical intensive care unit following the removal of a large portion of the intestines due to a gunshot wound to the abdomen. The client begins to display signs of septic shock and a sepsis protocol is initiated. Which intervention is most important for the nurse to include in the plan of care?