Which intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an intravenous (IV) site in the client’s arm?

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

A client on the mental health unit has been displaying signs of agitation, such as scowling and pacing rapidly up and down the hallway for several minutes.
Which behaviors should the nurse prioritize for monitoring?

While conducting an admission assessment of a female client with bipolar disorder, the client suddenly starts to undress and throw her clothes around the room.
What should be the nurse’s initial action?

The patient is a 75-year-old female who has been admitted to the preoperative area in preparation for pacemaker insertion.

She reports that she is undergoing this procedure because her heart rate has been consistently low, she feels constantly fatigued, and she has experienced one episode of fainting due to a low heart rate.

The patient has a history of progressively worsening symptomatic bradycardia and a history of atrial fibrillation, which is controlled by medication.

She has been off anticoagulants for four days in preparation for the procedure.

As the nurse prepares the patient’s plan of care, which four findings would indicate that it would be safe to administer the antibiotic vancomycin?

The nurse is caring for a client with a history of coronary artery disease who reports waking up with a sudden onset of vise-like chest pressure.

The client reports that the pain decreases at rest but continues to feel a constant mid-chest pressure. What intervention should the nurse perform in the immediate management of the client?

What intervention should the nurse perform in the immediate management of the client?

A client who follows Mormon beliefs is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request for this client? Select all that apply.

The charge nurse is observing a new nurse who is preparing to insert an intravenous (IV) catheter.

The new nurse has gathered supplies including intravenous catheters, an intravenous insertion kit, and a 4x sterile gauze dressing to cover and secure the insertion.

What action should the charge nurse take?

The nurse is collecting a heel-stick blood specimen for a neonatal screen, which includes thyroxine (T4) and thyroid- stimulating hormone (TSH) levels, prior to discharging a 2-day-old patient.
When the parents ask why these tests are being conducted, which explanation should the nurse provide?

A primary caregiver of an older adult client calls the nurse at the outpatient clinic due to a sudden onset of changes in the client’s behavior.

The caregiver reports to the nurse that the client normally is oriented and able to answer Questions but now is confused.

What action(s) should the nurse take? Select all that apply.

An adolescent arrives at the emergency department (ED) with a fever and persistent lower right quadrant abdominal pain.

The patient is anxious, fearful, and hyperventilating.

What acid-base imbalance does the nurse anticipate the patient will develop?