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.

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?

The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy express that their child wants to continue attending swimming classes.
How should the nurse respond?

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?

A patient with a history of adrenal insufficiency has been admitted to the intensive care unit due to an acute adrenal crisis.

The patient is experiencing nausea and joint pain.

The patient’s vital signs are as follows: temperature of 102 F (38.9° C), heart rate of 138 beats/minute, and blood pressure of 80/60 mm Hg. What is the first intervention the nurse should implement?

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.

A patient with diabetic peripheral neuropathy has been taking pregabalin for the past four days. Which finding would indicate to the nurse that the medication is effective?

The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours.
Which additional action should the nurse instruct the UAP to take each time the client is turned?

The client is a 55-year-old male who was admitted to the hospital 1 week ago for sepsis. The client has been intubated since admission.
Current ventilator settings are synchronized intermittent mandatory ventilation (SIMV) respiratory rate 15 breaths/minute, tidal volume (TV) 500 mL, fraction of inspired oxygen (FiO) 40%. Based on the client’s status at 1400, the nurse should plan to do which of the following?

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.

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?