A client with a venous ulcer, which has not responded to intravenous vancomycin treatment and is discharging pus, has been admitted with a potential infection of Vancomycin-Resistant Enterococci (VRE). Which nursing interventions should be included in the care plan? Select all that apply.

The nurse is implementing the plan of care for a client.

For each body system, identify the potential nursing intervention that would be appropriate for the care of the client. Each body system may support more than one potential nursing intervention.

Each category must have at least one response option selected.

The nurse is about to administer a histamine 2-receptor antagonist to a patient with peptic ulcer disease. What is the primary purpose of this class of medication?

A 10-year-old child with pneumonia is receiving oxygen at 5 L/minute via a nasal cannula.
When planning care for this child, what principle of oxygen administration should the nurse keep in mind?

A client with a deep vein thrombosis (DVT) in the left leg is on a heparin protocol. What is the most crucial intervention for the nurse to include in this client’s care plan?

Which assessment finding is most crucial when planning to provide a complete bed bath to a bedfast client?

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?

A patient is brought to the emergency department after falling from a ladder and is exhibiting signs of confusion and disorientation.

The spouse reports that the patient seemed to have lost consciousness.

The nurse has been provided with a list of current medications and healthcare power of attorney.

When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?

A client on the cardiac telemetry unit suddenly starts showing signs of ventricular fibrillation. The advanced cardiac life support (ACLS) team defibrillates the client, restoring a normal sinus rhythm. Later in the day, a family member Questions why the code was called, telling the nurse that the client has a living will.
How should the nurse respond?

A nurse is caring for a patient who suddenly experiences right-sided numbness and weakness in the arm and leg, along with a distinct droop on the right side of the face.

After reporting these findings to the healthcare provider, the nurse receives several prescriptions for the patient, including an immediate CT scan of the head.

What should be the nurse’s first course of action?

The nurse uses the Modified Caregiver Strain Index (MCSI) and determines that the daughter is experiencing significant stress due to taking on her mother’s care.

The nurse plans to discuss ways to reduce caregiver stress with the daughter.

Select three statements that the nurse should include in the discussion.