Dominate course Pre-Assessment Test

A nurse is floating from the medical-surgical unit to the oncology unit. Which client would be the most appropriate assignment for this nurse?. A 50-year-old client receiving their first dose of chemotherapy. A 63-year-old client with leukemia requiring routine oral medication. A 40-year-old client post-op day 1 from a mastectomy with new onset of shortness of breath. A 70-year-old client who just returned from surgery for tumor removal, requesting water to drink.

A nurse is caring for a client who is 2 hours postpartum. The client reports feeling dizzy and lightheaded. Upon assessment, the nurse notes that the uterine fundus is boggy, and the client's perineal pad is saturated with blood. What should the nurse do first?. Apply oxygen at 10 L/min via face mask. Increase the rate of the IV fluid infusion. Perform fundal massage until the uterus is firm. Assess blood pressure.

A nurse is reviewing an ECG strip (see exhibit). The nurse correctly identifies this rhythm as: Third degree heart block. Second Degree Type II heart block. First Degree AV Block. Second Degree Type I heart block.

Review the assessment findings and select the appropriate nursing interventions. For each intervention listed below, select whether it is Indicated or Not Indicated. Obtain sputum culture. Administer antipyretic for fever. Initiate oxygen therapy at 2 L/min via nasal cannula. Encourage ambulation twice daily. Administer 1L IV bolus of normal saline.

A 29-year-old primigravida at 38 weeks of gestation arrives at the labor and delivery unit with complaints of severe headache, visual disturbances, and epigastric pain. The nurse notes a blood pressure of 160/110 mmHg and 3+ proteinuria on urinalysis. Which interventions should the nurse implement? Select all that apply. Administer labetalol as prescribed. Monitor fetal heart rate continuously. Assess deep tendon reflexes (DTRs). I Prepare the client for an emergency cesarean section. Place the client on seizure precautions. Administer 500 mL IV bolus of lactated Ringer's.

A 32-year-old multipara at 36 weeks of gestation presents with painless vaginal bleeding. The client denies abdominal pain or uterine contractions. The nurse notes a fetal heart rate of 140 bpm with moderate variability on the monitor. Based on this presentation, which nursing interventions should be implemented? Select all that apply. Place the client on continuous fetal monitoring. Perform a sterile vaginal exam to assess for dilation. Administer Rho(D) immune globulin if the client is Rh-negative. I Initiate an IV line with large-bore access. Prepare the client for an immediate cesarean delivery.

A 40-year-old G2P1 client at 40 weeks of gestation is in active labor recieving oxytocin. The nurse observes late decelerations on the fetal heart rate monitor during contractions. The client is on 2 L/min of oxygen via nasal cannula, and her cervix is dilated to 8 cm. What should the nurse prioritize?. Increase oxygen to 10 L/min via oxygen mask. Notify the healthcare provider immediately. Reposition the client to a lateral position. Stop oxytocin infusion if it is running.

A 26-year-old client, G1P1, 24 hours postpartum, reports feeling lightheaded and dizzy while attempting to stand. The nurse observes heavy lochia rubra with several large clots. Vital signs reveal BP 85/55 mmHg, HR 138 bpm, and RR 22 breaths per minute. The nurse is tasked with identifying and managing the client's postpartum complication. For each potential intervention, select whether it is Indicated or Not Indicated. Massage the uterine fundus. Administer IV oxytocin as prescribed. Reassess vital signs in 15 minutes. Encourage ambulation. Initiate a second large-bore IV for fluids. Administer a blood transfusion as ordered. Monitor urine output via Foley catheter.

A nurse in a medical-surgical unit cares for multiple clients with varying needs. Based on delegation guidelines and infection control principles, identify appropriate interventions that are within the scope of practice for each healthcare team member. Administering IV antibiotics to a client with sepsis. Assisting a postoperative client with ambulation (3 days post-op). Performing a sterile dressing change on a wound. Collecting a urine specimen for culture. Educating a client about managing their new colostomy. Interpret an EKG Rhythm on a client with chest pain.

A 58-year-old client with a history of hypertension and coronary artery disease presents to the emergency department with complaints of persistent chest discomfort radiating to the left arm and jaw, accompanied by shortness of breath, nausea, and diaphoresis. Which of the following actions should the nurse perform first?. Administer nitroglycerin sublingually. Obtain a 12-lead EKG. Administer supplemental oxygen at 2 L/min via nasal cannula. Establish IV access for medication administration.

A nurse reviews the 12-lead EKG of a 65-year-old client presenting with chest pain. (See Exhibit). Administer oxygen via nasal cannula. Notify the healthcare provider. Assess the carotid pulse. Perform chest compressions immediately.

A 70-year-old client is admitted to the telemetry unit after complaints of dizziness, fatigue, and near-syncope episodes. The nurse observes the following findings on the EKG: a complete heart block (third-degree AV block) with a ventricular rate of 30 bpm. Which of the following nursing interventions are appropriate? Select all that apply. Prepare for transcutaneous pacing. Administer atropine as prescribed. Assess mental status. Administer IV fluids to improve perfusion. Perform synchronized cardioversion. Administer a cardiac glycoside STAT.

A 55-year-old client with a history of hypertension is prescribed lisinopril. During a follow-up visit, the nurse evaluates the client's response to the medication. Click to specify if the finding is consistent with an intended effect, side effect, or adverse effect of lisinopril?. Blood pressure reduced to 110/80 mmHg. Persistent dry cough for several days. Angioedema with facial swelling. Hyperkalemia. Dizziness and lightheadedness. Elevated creatinine level above 1.2 mg/dL.

A client with type 2 diabetes is prescribed metformin for glycemic control. During a follow-up visit, the nurse evaluates the client's understanding of the medication. Which of the following statements by the client indicate correct understanding? Select all that apply. "This medication helps lower my blood sugar by decreasing glucose production in my liver.". "I should take this medication with food to reduce stomach upset.". "If I experience muscle pain or extreme fatigue, I should contact my healthcare provider immediately.". "This medication might cause hypoglycemia if I skip meals.". "I will need to monitor my kidney function regularly while on this medication.". "If my blood glucose levels are within the normal range, I do not need to take the medication.".

A 68-year-old client receiving a continuous IV infusion of heparin for deep vein thrombosis (DVT) reports abdominal pain and notices blood in their stool. What is the nurse priority action?. Stop the heparin infusion immediately. Notify the healthcare provider immediately. Assess the client's coagulation profile (PTT/INR). Administer protamine sulfate as prescribed.

A nurse is caring for a client prescribed lithium for the management of bipolar disorder. During client education, the nurse identifies specific symptoms that may indicate lithium toxicity. Click to specify if the finding is consistent with mild, moderate, or severe toxicity. Coarse hand tremors. Slurred speech. Tonic-clonic seizures. Nausea and vomiting. Muscle twitching. Diminished concentration. Deep tendon hyper-reflexia.

A nurse is educating a client taking lithium for bipolar disorder on interventions to prevent lithium toxicity. Which of the following statements indicate proper client understanding? Select all that apply. "I will drink 6 to 8 glasses of water each day.". "I can take a missed dose within 2 hours of the scheduled time.". "I should avoid alcohol while taking lithium.". "I will stop lithium immediately if I experience side effects.". "I should maintain consistent sodium intake in my diet.". "I can use over-the-counter pain medications without consulting my healthcare provider.".

A nurse is assessing a client taking lithium who reports nausea and slight hand tremors. The client's healthcare provider recently increased their lithium dose to better manage bipolar disorder symptoms. Which of the following actions should the nurse take first?. Continue to monitor the client. Administer antiemetic medication. Assess the client's current lithium level. Instruct the client to drink more water.

A nurse is caring for a client prescribed digoxin for heart failure management. The nurse is teaching the client about the medication. Which of the following statements made by the client indicates a need for further education? Select all that apply. "I will check my pulse before taking my medication and notify my provider if it is below 60 beats per minute.". " If I experience blurred vision, I will report these symptoms to my healthcare provider immediately.". "I can take over-the-counter medications like antacids while taking Digoxin.". "Eating foods high in potassium is unnecessary since I am taking digoxin.". "If I have nausea and vomiting it is an indication I should take the medication with food.".

A client with heart failure is prescribed digoxin. The nurse reviews the client's lab results and observes the following: Serum potassium: 3.1 mEq/L (normal range: 3.5-5.0 mEq/L) Serum digoxin: 2.0 ng/mL (normal range: 0.5-2.0 ng/mL) Serum creatinine: 1.3 mg/dL (normal range: 0.6-1.2 mg/dL) The nurse receives results from the laboratory. What is the nurse's priority action?. Administer a potassium supplement. Administer a potassium supplement. Hold the digoxin and contact the Health Care Provider (HCP). Administer the digoxin as prescribed.

A client has been prescribed digoxin for atrial fibrillation. The nurse is reviewing the client's medications and recent lab results: Medications: . Furosemide 40 mg daily · Potassium chloride 20 mEq daily . Digoxin 0.125 mg daily Lab Results: · Serum potassium: 4.0 mEq/L (normal range: 3.5-5.0 mEq/L) · Serum digoxin: 1.2 ng/mL (normal range: 0.5-2.0 ng/mL) The nurse reviews the new medication orders and laboratory results. Which of the following findings is most concerning to the nurse?. Client reports seeing halos around lights. Client has an apical pulse of 72 beats per minute. Client reports frequent urination during the day. Client denies any symptoms and feels well.

A nurse provides care to assigned clients at the start of the shift. Which client should the nurse assess first?. A client just arrived from the emergency department, reporting mild dizziness. A client who recently received nitroglycerin for chest pain rated as 3 out of 10 on the pain scale. A client who underwent a morning coronary angiogram and has warm feet with strong pedal pulses. A client who has frequently used the call bell, expressing dissatisfaction with care.

A nurse is preparing to administer medications for their assigned clients during a busy morning shift. Which medication administration is the priority?. Administer the antihypertensive to a client with a blood pressure of 170/95 mmHg who reports no symptoms. Administer the potassium supplement to a client with a potassium level of 3.1 mEq/L who has mild leg cramps. Administer the antiarrhythmic to a client exhibiting signs of atrial fibrillation with a heart rate of 130 bpm and mild chest discomfort. Administer the antipyretic to a client with a fever of 102°F (38.9C) who is reporting fatigue.

A client with a history of cardiovascular disease reports a burning sensation in the stomach after taking their morning medications. The client's current prescriptions include a beta-blocker, anticoagulant, and a statin. What should the nurse do first?. Evaluate the client for signs of gastric irritation or potential bleeding. Suggest the client reduce the anticoagulant dosage temporarily. Educate the client on taking medications with food to minimize discomfort. Advise the client to consult their healthcare provider for alternative medication options.

A nurse on a medical-surgical unit is reviewing the condition of their assigned clients at the beginning of the shift. Which client should the nurse prioritize for immediate intervention?. A client who has a new onset of slurred speech and right-sided weakness. A client reporting nausea after receiving antibiotics one hour ago. A client with a blood glucose level of 250 mg/dL. A client with mild shortness of breath after ambulating to the bathroom.

Which tasks should the nurse delegate to the unlicensed assistive personnel (UAP) when caring for a client who is 1-day post-op following abdominal surgery? Select all that apply. Educate the client on the importance of deep breathing and coughing exercises. Assess the client's abdominal incision for signs of infection. Measure and record the client's intake and output. Assist the client with repositioning every 2 hours to prevent pressure injuries. Empty and record the contents of the client's surgical drain.

A client who recently traveled to a region experiencing an outbreak of Severe Acute Respiratory Syndrome (SARS) arrives at the emergency department (ED) with severe respiratory symptoms and an oxygen saturation of 82%. Which of the following prescribed actions will the nurse implement first?. Provide oxygen therapy using a high-flow nasal cannula to improve oxygen saturation levels. Collect nasopharyngeal swabs and sputum samples for SARS-CoV-2 testing. Initiate airborne, droplet, and contact precautions to prevent the spread of SARS. Administer antipyretics and provide supportive care to manage symptoms and fever.

A client arrives at the emergency department (ED) after being bitten by a rattlesnake while hiking. The client exhibits localized swelling, pain, nausea and a rapid heart rate. Which of the following actions will the nurse implement first?. Immobilize the affected limb and position the extremity above the level of the heart to reduce venom spread. Administer antivenom as prescribed to counteract the venom's effects. Apply a tourniquet distal to the bite site to prevent systemic spread. Start intravenous fluids immediately to address potential hypotension and shock.

A client presents to the emergency department (ED) with a history of recent travel to a malaria-endemic region. The client exhibits severe symptoms, including high fever (104°F/40℃), chills, altered mental status, blood pressure (85/50 mmHg), and signs of acute kidney injury. Which of the following actions will the nurse implement first?. Administer chloroquine phosphate PO to treat the malaria infection. Initiate transmission-based precautions to prevent the spread of infection. Monitor urine output and assess for worsening signs of renal failure. Start intravenous fluids to manage dehydration and support renal perfusion.

A nurse is reviewing the status of four clients who recently underwent surgical procedures. Which client should the nurse assess first?. A client who is 8 hours post-abdominal surgery with decreased bowel sounds. A client who is 4 hours post-hip replacement with a blood pressure of 88/56 mmHg and reports feeling lightheaded. A client who is 6 hours post-thoracic surgery with an oxygen saturation of 89% on 2L/min via nasal cannula and reports slight shortness of breath. A client who is 12 hours post-cholecystectomy with a temperature of 101.2°F (38.4C) and reports severe abdominal pain.

A nurse provides end-of-life care to a client with terminal cancer. The doctor has ordered comfort measures only (CMO). Which interventions should the nurse include in the care plan? Select all that apply. Administer pain medication as prescribed to ensure the client is comfortable. Discourage the family to spend time with the client and provide emotional support. Monitor for Cheyne-Stokes respirations and provide reassurance to the family. Respect cultural and religious practices related to end-of-life care. Perform deep suctioning to manage secretions and noisy breathing. Initiate cardiopulmonary resuscitation (CPR) in the event of cardiac arrest. Maintain skin integrity by regularly repositioning the client.

The nurse is mentoring a new graduate nurse and provides a teaching session to clarify the difference between collaborative and independent nursing actions. Match the following nursing interventions with the appropriate category: Collaborative Intervention or Independent Nursing Action. Administering prescribed antibiotics. Assessing vital signs. Educating a client about their diet. Repositioning a client for comfort. Adjusting prescribed IV fluid rates.

The nurse is prioritizing care for several clients. Which of the following collaborative interventions should the nurse perform first?. Administering prescribed IV antibiotics for a client with pneumonia and a fever of 101.5°F (38.6°C). Assessing the client's pain after administering medications for a headache. Educating a client recently diagnosed with type 2 diabetes on glucose monitoring. Adjusting prescribed IV fluid rates for a client who is post-operative and experiencing hypotension.

Which nursing problem is the highest priority for a client diagnosed with acute dehydration due to excessive vomiting?. Impaired tissue perfusion. Fluid volume deficit. Risk for impaired skin integrity. Altered nutrition: less than body requirements.

Which nursing interventions are appropriate for a client receiving total parenteral nutrition (TPN)? Select all that apply. Monitor blood glucose levels regularly to detect hyperglycemia. Administer TPN through a peripheral IV line to ensure comfort. Assess the central line insertion site for redness, swelling, or drainage. Use clean technique while providing central line care. Monitor weight gain and laboratory values, such as albumin and prealbumin, to evaluate nutritional status. Administer lipids quickly to prevent delays in nutritional therapy.

A nurse is caring for a client receiving total parenteral nutrition (TPN) via a central line. Which of the following should the nurse address first?. The client's blood glucose is 250 mg/dL. The central line insertion site is warm and red. The TPN infusion pump is beeping due to an empty bag. The client reports shortness of breath and has a heart rate of 110 bpm.

The client has received IV antibiotics for 2 days through an 18-gauge IV catheter placed in the right basilic vein. On morning rounds, the nurse notes the IV site is swollen, warm to the touch, and leaking fluid. Which interventions should the nurse implement first?. Discontinue the intravenous line. Elevate the affected arm. Place a cold compress on the site to reduce swelling. Insert a new IV line in the left forearm.

A 65-year-old client underwent a Transurethral Resection of the Prostate (TURP) procedure two days ago and is recovering on the urology floor. The nurse is conducting assessments and identifying key interventions to ensure proper post-operative care. The client has a three-way catheter in place and is receiving continuous bladder irrigation. During rounds, the nurse observes clear amber urine with occasional light pink streaks and notes the client ambulating with assistance. Identify which of following nursing interventions related to the post-TURP (Transurethral Resection of the Prostate) are appropriate or not appropriate. Monitor urinary output and urine for hemorrhage or clots. Increase fluids to 500 to 1500 mL/day. In the presence of bright red urine with clots; increase Continuous Bladder Irrigation (CBI). During assessment expect red to light pink urine for 24 hours. Ambulate the client as early as possible per doctor's orders. Maintain CBI with sterile bladder irrigation solution as prescribed to keep the catheter free of obstruction. If the urinary catheter becomes obstructed do not irrigate the catheter and notify the surgeon.

A 68-year-old client is recovering from a Transurethral Resection of the Prostate (TURP) procedure performed 24 hours ago. The nurse notes that the client is receiving continuous bladder irrigation (CBI) through a three-way catheter. During a routine assessment, the nurse observes bright red urine, decreased urinary output, numerous clots, and the client complains of bladder spasm. Which of the following interventions should the nurse prioritize post TURP procedure?. Increase the rate of continuous bladder irrigation to clear the catheter tubing. Assess the client's intake and output to evaluate hydration status. Notify the healthcare provider about the client's symptoms and findings. Administer antispasmodics as prescribed.

A nurse arrives at the scene of a construction accident where a worker has fallen approximately 15 feet from scaffolding. The client is found lying on the ground, unresponsive, with visible abrasions on the arms and legs. Witnesses report that the client landed on their back. Which action should the nurse implement first?. Stabilize the client's cervical spine to prevent spinal cord injury. Check for external bleeding and control it with pressure if present. Ensure the client has a patent airway to maintain oxygenation. Assess for other visible injuries and perform a quick head-to-toe assessment.

A nurse is working on an endocrinology unit and receives the following client assignments. Which client should the nurse prioritize seeing first?. A client with diabetes mellitus who reports a blood glucose level of 55 mg/dL and feels shaky and lethargic. A client with hyperthyroidism who has a heart rate of 125 bpm and reports mild hand tremors. A client with hypothyroidism who is experiencing fatigue and dry skin. A client with Cushing's syndrome who reports increased thirst and a blood pressure of 150/90 mmHg.

A nurse, off duty during a storm, observes an individual lying unresponsive on the ground in a puddle of water with a black cable submerged nearby. What action should the nurse implement first?. Call 911 and request emergency assistance. Assess the individual for breathing and check for a pulse. Remove the individual from the puddle of water. Perform CPR if the individual is not breathing and has no pulse.

Which nursing interventions are appropriate for a client diagnosed with Syndrome of Inappropriate Antidiuretic Hormone (SIADH)? Select all that apply. Restrict fluid intake to correct hypernatremia. Monitor daily weight and report significant changes to the health care provider. Assess for changes in neurological status. Administer vasopressin per doctor's order. Monitor serum sodium levels frequently. Assess for signs of fluid volume overload.

A nurse is caring for a client with Syndrome of Inappropriate Antidiuretic Hormone (SIADH) who has been admitted with complaints of confusion, headache, and a serum sodium level of 118 mEq/L. During the nurse's assessment, the client's condition worsens, and they exhibit lethargy and signs of fluid overload, including crackles in the lungs and jugular vein distension. Which action should the nurse perform first?. Administer prescribed hypertonic saline via IV infusion. Restrict the client's fluid intake to no more than 800 mL per day. Notify the healthcare provider immediately about the client's symptoms. Position the client with the head of the bed elevated at 45 degrees.

A nurse is caring for a 45-year-old client admitted with Diabetes Insipidus (DI) following a head injury. The client is experiencing excessive urine output and extreme thirst, reporting fatigue and dizziness. Identify which nursing interventions are appropriate or not appropriate to address a client with Diabetes Insipidus?. Administer Desmopressin acetate (DDAVP). Restrict fluid intake to prevent overhydration. Monitor serum sodium and osmolality levels. Provide a diet high in sodium. Monitor daily weight. Administer hypotonic saline.

A nurse is caring for a client diagnosed with Diabetes Insipidus (DI) who has been experiencing polyuria and polydipsia for the past 48 hours. The client reports extreme fatigue, dizziness, and a headache. Lab results reveal a serum sodium level of 158 mEq/L and a urine specific gravity of 1.003. Which action should the nurse prioritize?. Administer Desmopressin acetate (DDAVP) as prescribed. Administer hypotonic saline. Notify the healthcare provider immediately about the client's symptoms. Teach the client the importance of fluid intake.

The nurse is teaching a new graduate nurse about clients admitted with Syndrome of Inappropriate Antidiuretic Hormone (SIADH) and Diabetes Insipidus (DI). To assess the graduate nurse's understanding, the nurse provides the following client findings and asks the graduate to differentiate whether each finding is associated with SIADH or DI. Identify the following client findings to the correct condition: SIADH or DI. Low urine output with concentrated urine. High serum sodium level. Dilutional hyponatremia. Extreme thirst (polydipsia). Urine specific gravity less than 1.005. Weight gain due to fluid retention. Dehydration symptoms, including dry mucous membranes.

A nurse is assessing fetal heart rate (FHR) patterns during labor to determine fetal well-being. The nurse observes a variety of patterns on the fetal monitor strip. Differentiate between reassuring and non-reassuring fetal heart rate (FHR) patterns using the chart below. The average FHR over a 10-minute period (110-160 BPM). Sustained FHR > 160 BPM for more than 10 minutes. Sustained FHR < 110 BPM for more than 10 minutes. Transient increases of fetal heart rate ≥ 15 BPM above baseline lasting ≥ 15 seconds. Early Decelerations: Gradual decreases in FHR mirroring contractions. Late Decelerations: Gradual decreases in FHR beginning after the contraction starts. Variable Decelerations: Abrupt decreases in FHR unrelated to contractions.

A nurse is monitoring a laboring client and observes early decelerations on the fetal heart rate monitor. The client is in active labor, and the FHR baseline is 140 BPM. What is the nurse's priority action?. Reposition the client to the left lateral position. Notify the healthcare provider immediately. Continue monitoring the fetal heart rate and contractions. Administer oxygen via facemask at 8-10 L/min.

A nurse is providing care to clients in the labor and delivery department and is doing rounds. During an assessment, the nurse observes variable decelerations on the fetal heart rate monitor of one client. What is the nurse's priority action?. Reposition the client to the left lateral position. Notify the healthcare provider immediately. Administer intravenous fluids to improve placental perfusion and support fetal oxygenation. Administer oxygen via facemask at 8-10 L/min STAT.

A nurse is providing care to clients in the labor and delivery department. During rounds, the nurse receives reports of the following clients. Which client should the nurse prioritize seeing first?. A client in active labor with contractions every 3 minutes, reporting severe pain and cervical dilation of 8 cm. A client with bright red vaginal bleeding, no contractions, BP 125/85, HR 102. A client with cervical dilation of 6 cm and a baseline fetal heart rate of 120 BPM whose contractions stopped abruptly. A client with a baseline fetal heart rate of 170 BPM, mild contractions every 10 minutes, and no cervical changes.

A nurse in the labor and delivery department is managing care for four clients with varying levels of urgency. Which client should the nurse assess first?. A client with cervical dilation of 4 cm, contractions every 5 minutes, moderate pain rated 6/10, and occasional decelerations on the fetal monitor. A client with sudden onset of intense abdominal pain, vaginal bleeding, BP 90/60, and reports of no fetal movement in the last hour. A client with spontaneous rupture of membranes 2 hours ago, clear fluid, a baseline fetal heart rate of 140 BPM, and mild cramping. A client with a baseline fetal heart rate of 100 BPM, contractions every 3 minutes, and reports of excessive fatigue and decreased variability on the fetal monitor.

A nurse is teaching a new graduate nurse about findings in clients with pre-eclampsia and eclampsia. Which of the following nurse statements are consistent with pre-eclampsia or eclampsia. Select all that apply. Persistent hypertension ≥140/90 mm Hg is a clinical finding consistent with both pre-eclampsia and eclampsia. Seizures or coma are clinical findings consistent with preeclampsia. Proteinuria is a clinical finding consistent with both pre-eclampsia and eclampsia. Headache and visual disturbances are clinical findings consistent with both pre-eclampsia and eclampsia. Right upper quadrant or epigastric pain is a clinical finding consistent only in eclampsia. Severe end-organ damage is a clinical finding consistent with pre-eclampsia.

A nurse is providing care to clients in the antepartum unit. Which interventions are appropriate or not appropriate for a client with eclampsia?. Administer magnesium sulfate as prescribed. Monitor reflexes and respiratory status. Position the client supine to improve comfort. Provide oxygen at 8-10 L/min via mask. Remain with the client during a seizure. Encourage oral fluids to maintain hydration.

A nurse in the labor and delivery unit is caring for a client with eclampsia who has just experienced a seizure. The client is unresponsive and has a blood pressure of 190/110 mm Hg, a respiratory rate of 10 breaths per minute, and oxygen saturation of 88% on room air. What is the nurse's highest priority?. Assess the client's deep tendon reflexes. Administer oxygen via non-rebreather mask. Obtain a stat order for an antihypertensive medication. Position the client on her side.

A nurse in the labor and delivery unit is caring for a client with eclampsia who is experiencing decreased urinary output of 20 mL/hr, generalized edema, and worsening headache despite magnesium sulfate therapy. The nurse observes a sudden drop in oxygen saturation to 85% and notes frothy sputum. What immediate action should the nurse take?. Increase the infusion rate of magnesium sulfate. Administer a diuretic as prescribed. Apply high-flow oxygen via face mask at 10-15 L/min. Notify the healthcare provider immediately.

A nurse in the psychiatric unit is managing a client exhibiting escalating violent behavior. The client is pacing, agitated, and making verbal threats. What actions should the nurse take to ensure safety and de-escalate the situation? Select all that apply. Maintain a calm and non-threatening approach. Set clear and consistent limits on behavior. Stand directly in front of the client to establish authority. Offer choices to help the client feel a sense of control. Remove hazardous objects from the environment. Use restraints immediately to ensure safety. Transfer the client to a seclusion room.

A nurse in the psychiatric unit is managing a client who has become violent, throwing objects, kicking, and yelling at other clients. What is the nurse's priority intervention?. Administer prescribed sedative medication. Use a calm tone to attempt verbal de-escalation. Request immediate assistance from other staff members. Apply two-point restraints to the client's arms.

During a training session led by the nursing supervisor, a nurse is evaluating client situations to determine whether a voluntary or involuntary admission is appropriate. The supervisor highlights the importance of understanding the legal and ethical considerations of both types of admissions to ensure proper application in practice. Review the chart below and identify if each client situation relates to a voluntary or involuntary admission. The client voluntarily seeks care and treatment. The client has been deemed a danger to themselves or others by a health care provider, judge, or law enforcement. The client can request to leave against medical advice. The client requires mandatory hospital admission. Detaining the client against their will constitutes false imprisonment.

A nurse is managing a client diagnosed with schizophrenia who is experiencing auditory hallucinations. What are appropriate nursing interventions for this client? Select all that apply. Engage the client in a reality-based activity. Ask the client to describe what the voices are saying. Monitor the client for increasing agitation or signs of anxiety. Acknowledge the client's feelings but avoid validating the hallucinations as real. Tell the client that the hallucinations are not real, and they should ignore them. Move the client to a quiet, low-stimulus environment.

A client with schizophrenia is experiencing auditory and visual hallucinations. The client reports hearing voices commanding them to harm themselves and seeing threatening shadows in the room. What is the nurse's priority intervention?. Administer prescribed antipsychotic medication. Sit with the client and explore their feelings about the hallucinations. Ensure the environment is safe by removing any potentially harmful objects. Move the client to a quieter area to reduce stimulation.

A nurse working on a psychiatric unit is reviewing the following client situations. Which client should the nurse prioritize attending to first?. A client with post-traumatic stress disorder (PTSD) who is crying uncontrollably and refusing to speak to staff. A client with borderline personality disorder who is sitting quietly but has superficial scratches on their forearm from self-harm earlier in the shift. A client with paranoid schizophrenia who is standing in the corner of the room, shouting, "You're trying to kill me!". A client with obsessive-compulsive disorder (OCD) who is repeatedly washing their hands and is anxious that the sink may not be clean.

The nurse in the emergency department is caring for a 45-year-old male. Nurse's Notes Emergency Room 1000: The client arrives presenting with abdominal pain. The client reports nausea, vomiting, and decreased appetite for the past week, noting that the nausea has progressively worsened, and the episodes of vomiting have become more frequent over the last 10 hours. The pain initially started as mild discomfort around the umbilical area but has now localized to the right lower quadrant (RLQ). The client rates the pain as 8/10. Past medical history includes hypertension managed with lisinopril, a history of smoking (1 pack/day for 20 years), and occasional alcohol use. He works a sedentary desk job and admits to limited physical activity. The client's lifestyle includes a diet high in processed foods and irregular meal patterns. 1015: Client reports worsening abdominal pain. Rebound tenderness and guarding are noted in the RLQ on physical examination, with the client exhibiting severe pain and significant guarding upon palpation. The client is visibly uncomfortable and diaphoretic. Vital Signs Emergency Room 1000: Temperature: 102.3°F (39.1℃) Heart Rate: 120 bpm Respiratory Rate: 22 breaths per minute Blood Pressure: 138/85 mmHg Laboratory Results Emergency Room 1000: White Blood Cell Count (WBC): 18,000/mm3 (range: 5,000-10,000/mm3) Hemoglobin: 13 g/dL (range: Male 14-18 g/dL, Female 12-16 g/dL) Platelets: 250,000/mm3 (range: 150,000-400,000/mm3) C-reactive Protein (CRP): Elevated (normal range: <10 mg/L) Which of the following findings should the nurse prioritize for follow-up? Select all that apply. Vital Signs. White blood cell count of 18,000/mm3. Hemoglobin of 13 g/dL. Client's history of occasional alcohol use. Rebound tenderness and guarding in RLQ. History of Smoking.

The nurse in the emergency department is caring for a 45-year-old male. Emergency Room 1000: The client arrives presenting with abdominal pain. The client reports nausea, vomiting, and decreased appetite for the past week, noting that the nausea has progressively worsened, and the episodes of vomiting have become more frequent over the last 10 hours. The pain initially started as mild discomfort around the umbilical area but has now localized to the right lower quadrant (RLQ). The client rates the pain as 8/10. Past medical history includes hypertension managed with lisinopril, a history of smoking (1 pack/day for 20 years), and occasional alcohol use. He works a sedentary desk job and admits to limited physical activity. The client's lifestyle includes a diet high in processed foods and irregular meal patterns. 1015: Client reports worsening abdominal pain. Rebound tenderness and guarding are noted in the RLQ on physical examination, with the client exhibiting severe pain and significant guarding upon palpation. The client is visibly uncomfortable and diaphoretic. Vital Signs Emergency Room 1000: Temperature: 102.3°F (39.1℃) Heart Rate: 120 bpm Respiratory Rate: 22 breaths per minute Blood Pressure: 138/85 mmHg Laboratory Results Emergency Room 1000: White Blood Cell Count (WBC): 18,000/mm3 (range: 5,000-10,000/mm3) Hemoglobin: 13 g/dL (range: Male 14-18 g/dL, Female 12-16 g/dL) Platelets: 250,000/mm3 (range: 150,000-400,000/mm3) C-reactive Protein (CRP): Elevated (normal range: <10 mg/L) For each assessment finding below, click to specify if the finding is consistent with the disease process of appendicitis, gastroenteritis, or diverticulitis. Each finding may support more than one disease process. Right lower quadrant (RLQ) pain. Elevated white blood cell count. Fever. Nausea and vomiting. Rebound tenderness. Diarrhea.

The nurse in the emergency department is caring for a 45-year-old male. Emergency Room 1000: The client arrives presenting with abdominal pain. The client reports nausea, vomiting, and decreased appetite for the past week, noting that the nausea has progressively worsened, and the episodes of vomiting have become more frequent over the last 10 hours. The pain initially started as mild discomfort around the umbilical area but has now localized to the right lower quadrant (RLQ). The client rates the pain as 8/10. Past medical history includes hypertension managed with lisinopril, a history of smoking (1 pack/day for 20 years), and occasional alcohol use. He works a sedentary desk job and admits to limited physical activity. The client's lifestyle includes a diet high in processed foods and irregular meal patterns. 1015: Client reports worsening abdominal pain. Rebound tenderness and guarding are noted in the RLQ on physical examination, with the client exhibiting severe pain and significant guarding upon palpation. The client is visibly uncomfortable and diaphoretic. Vital Signs Emergency Room 1000: Temperature: 102.3°F (39.1℃) Heart Rate: 120 bpm Respiratory Rate: 22 breaths per minute Blood Pressure: 138/85 mmHg Laboratory Results Emergency Room 1000: White Blood Cell Count (WBC): 18,000/mm3 (range: 5,000-10,000/mm3) Hemoglobin: 13 g/dL (range: Male 14-18 g/dL, Female 12-16 g/dL) Platelets: 250,000/mm3 (range: 150,000-400,000/mm3) C-reactive Protein (CRP): Elevated (normal range: <10 mg/L) Based on the client's symptoms, select the 3 complications the client is at risk for developing. Peritonitis. Septic shock. Pulmonary embolism. Bowel obstruction. Hypovolemia. Appendiceal rupture. Urinary tract infection.

The nurse in the emergency department is caring for a 45-year-old male. Emergency Room 1000: The client arrives presenting with abdominal pain. The client reports nausea, vomiting, and decreased appetite for the past week, noting that the nausea has progressively worsened, and the episodes of vomiting have become more frequent over the last 10 hours. The pain initially started as mild discomfort around the umbilical area but has now localized to the right lower quadrant (RLQ). The client rates the pain as 8/10. Past medical history includes hypertension managed with lisinopril, a history of smoking (1 pack/day for 20 years), and occasional alcohol use. He works a sedentary desk job and admits to limited physical activity. The client's lifestyle includes a diet high in processed foods and irregular meal patterns. 1015: Client reports worsening abdominal pain. Rebound tenderness and guarding are noted in the RLQ on physical examination, with the client exhibiting severe pain and significant guarding upon palpation. The client is visibly uncomfortable and diaphoretic. Vital Signs Emergency Room 1000: Temperature: 102.3°F (39.1℃) Heart Rate: 120 bpm Respiratory Rate: 22 breaths per minute Blood Pressure: 138/85 mmHg Laboratory Results Emergency Room 1000: White Blood Cell Count (WBC): 18,000/mm3 (range: 5,000-10,000/mm3) Hemoglobin: 13 g/dL (range: Male 14-18 g/dL, Female 12-16 g/dL) Platelets: 250,000/mm3 (range: 150,000-400,000/mm3) C-reactive Protein (CRP): Elevated (normal range: <10 mg/L) Diagnostic Results Emergency Room 1100: A diagnosis of acute appendicitis is confirmed based on clinical findings and imaging results. A CT scan of the abdomen revealed an inflamed appendix with thickened walls and peri-appendiceal fluid, consistent with appendicitis. After reviewing diagnostic results, the client is scheduled for an emergency appendectomy. Which of the following nursing interventions are indicated or not indicated?. Ensure the client is NPO prior to surgery. Administer prescribed IV antibiotics. Apply heat to the abdomen to reduce pain. Monitor vital signs for signs of sepsis. Provide laxatives to relieve bowel obstruction. Position the client in the right side-lying position.

The nurse in the emergency department is caring for a 45-year-old male. Emergency Room 1000: The client arrives presenting with abdominal pain. The client reports nausea, vomiting, and decreased appetite for the past week, noting that the nausea has progressively worsened, and the episodes of vomiting have become more frequent over the last 10 hours. The pain initially started as mild discomfort around the umbilical area but has now localized to the right lower quadrant (RLQ). The client rates the pain as 8/10. Past medical history includes hypertension managed with lisinopril, a history of smoking (1 pack/day for 20 years), and occasional alcohol use. He works a sedentary desk job and admits to limited physical activity. The client's lifestyle includes a diet high in processed foods and irregular meal patterns. 1015: Client reports worsening abdominal pain. Rebound tenderness and guarding are noted in the RLQ on physical examination, with the client exhibiting severe pain and significant guarding upon palpation. The client is visibly uncomfortable and diaphoretic. Day 1 Post Surgical Procedure 0800: The client reports minimal pain at the surgical site, rating it as 3/10, and has been able to tolerate prescribed oral analgesics effectively. The client has successfully ambulated 50 feet in the hallway with minimal assistance and used the incentive spirometer correctly, achieving a volume of 1500 mL, which supports lung expansion. Bowel sounds are slightly diminished, no nausea or vomiting present at this time Vital Signs Emergency Room 1000: Temperature: 102.3°F (39.1C) Heart Rate: 120 bpm Respiratory Rate: 22 breaths per minute Blood Pressure: 138/85 mmHg Day 1 Post Surgical Procedure Vitals 0800 Temperature of 99.6°F (37C) Heart rate of 78 bpm Respiratory rate of 18 breaths per minute, Blood pressure of 120/80 mmHg. Laboratory Results Emergency Room 1000: White Blood Cell Count (WBC): 18,000/mm3 (range: 5,000-10,000/mm3) Hemoglobin: 13 g/dL (range: Male 14-18 g/dL, Female 12-16 g/dL) Platelets: 250,000/mm3 (range: 150,000-400,000/mm3) C-reactive Protein (CRP): Elevated (normal range: <10 mg/L) Diagnostic Results 1100: A diagnosis of acute appendicitis is confirmed based on clinical findings and imaging results. A CT scan of the abdomen revealed an inflamed appendix with thickened walls and peri-appendiceal fluid, consistent with appendicitis. The nurse has reviewed the Nurses' Notes and Vital Signs. Which of the following postoperative interventions are appropriate or not appropriate? Select all that apply. Encourage use of the incentive spirometer every 1-2 hours. Administer prescribed oral analgesics as needed for pain. Ambulate the client once per day. Provide a clear liquid diet until bowel sounds normalize. Apply heat packs to the surgical site to reduce pain. Continue to monitor vital signs every 12 hours. Assess incision for signs of infection.

The nurse manager is auditing patient care to identify potential negligence or malpractice. Review the examples below and select the correct classification for each action (Negligence or Malpractice) in the table provided. A nurse administers a medication without verifying allergies. A nurse fails to secure side rails resulting in a fall, resulting in injury to the client. A nurse fails to adequately monitor a client's condition. A nurse fails to monitor IV flow rate leading to infiltration. The nursing assistant leaves a patient unattended in the bathroom who is at high risk for falls.

A nurse is caring for a client with a chest tube following a pneumothorax. Upon assessment, the nurse notices continuous bubbling in the water seal chamber of the chest drainage system. Which action should the nurse take first?. Notify the healthcare provider immediately. Check the chest tube connections for air leaks. Clamp the chest tube near the insertion site. Reposition the client to improve drainage.

A client presents to the emergency department with a severe allergic reaction after eating shellfish. The client is dyspneic, has stridor, and is hypotensive. What is the nurse's priority action?. Administer epinephrine intramuscularly. Start an intravenous infusion of normal saline. Place the client in a supine position with legs elevated. Administer diphenhydramine intravenously.

A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy at 2 L/min via nasal cannula. The client reports an increasing shortness of breath while ambulating. Which of the following actions should the nurse take first?. Increase the oxygen flow rate to 6 L/min. Assess the client's respiratory rate and oxygen saturation. Notify the healthcare provider immediately. Administer a prescribed bronchodilator.