A client with a full-thickness burn to the front of the left leg underwent skin grafting.
The nurse notes pain 6/10, dressing dry and intact, and slight edema at the graft site. Which action is the priority?

A client presents to the emergency department with a sudden onset of left-sided weakness, difficulty speaking, and a facial droop on the left side.
Which action should the nurse prioritize?

A nurse is caring for a client who has liver cirrhosis with ascites, bleeding esophageal varices, and portal hypertension.
The nurse recognizes which of the following laboratory findings as indicating the client's gastrointestinal (GI) tract is digesting and absorbing blood?

A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding.
The nurse notes: HR increased from 88 to 118/min over 1 hour, BP decreased from 124/78 to 98/60 mm Hg, urine output is 20 mL/hr, skin is cool and pale, and the client reports incisional pain 6/10. Which finding is the most concerning for hypovolemic shock?

A client is in the acute phase of a burn injury. The nurse notes a Mean Arterial Pressure (MAP) of 74 mm Hg, urine output of 95 mL/hr, and a temperature of 38.6°C (101.5°F). The white blood cell (WBC) count is 18,000/mm and the burn wound has increased drainage with a foul odor.
What is the priority nursing action?

A client in the rehabilitative phase of a burn injury has healed graft sites and is beginning mobility exercises.
Which intervention is most important to minimize scarring and promote functional recovery?

The nurse is caring for the terminally ill client.
Which interventions should the nurse implement to help minimize the stress and frustration experienced by the client and their family? Select all that apply.

A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath.
Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?

The nurse is performing a neurologic assessment on a client admitted for possible stroke.
Which technique should the nurse adopt to ensure an accurate assessment?

The nurse reviews a note for a client who reports sharp chest pain that hurts worse when taking a deep breath and restlessness. The client's vital signs are Temperature 100 F (37.8 C), HR 104 BPM, RR 20 bpm with dyspnea, BP 114/62 mm Hg, and SpO2 90 percent on room air.
The nurse develops a plan of care to manage the client's suspected condition. Select six actions that would be appropriate for the nurse to include in the plan.

A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy.
The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?