A client with diabetic ketoacidosis (DKA) is receiving an IV infusion of 0.9% sodium chloride and insulin.
Two hours later, the client’s serum laboratory results show a decrease in the serum blood glucose from 580 to 430 mg/dL (32.2 to 23.86 mmol/L). What additional laboratory result is most important for the nurse to monitor?

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?

A client with schizophrenia is admitted to the hospital reporting auditory hallucinations. Which query is most important for the nurse to include in the client’s assessment?

The nurse is developing the plan of care for a client diagnosed with Cushing’s syndrome and identifies that the client’s risk factors include poor wound healing, decreased bone density, and increased capillary fragility.
Which outcome statement should the nurse include in the plan of care?

What action should the school nurse take to provide secondary prevention for school-aged children?

A patient admitted to the hospital with a suspected ruptured diverticulum develops signs and symptoms of septic shock.

The healthcare provider prescribes a sepsis protocol.

Which intervention is most important for the nurse to include in the plan of care?

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.

A client with a history of heart failure arrives at the emergency department describing an onset of fatigue and weakness.

The client has been taking spironolactone 50 mg tablets PO every day.

The nurse receives a report from the lab that the client has a serum potassium level of 6.2 mEq/L (6.2 mmol/L). Which intervention is most important for the nurse to implement?

The nurse is providing postoperative care for an adolescent who had a left leg amputation due to osteosarcoma and is experiencing phantom limb pain.
What non-pharmacological intervention should the nurse provide?

The nurse is caring for a client with decompensated liver disease who is experiencing fever, chills, and abdominal tenderness.

Following a paracentesis, the nurse receives laboratory results of the ascitic fluid that show the polymorphonuclear leukocyte count is 425/mm (0.42 x 10/L). After notifying the healthcare provider, what action should the nurse take next?

The nurse identifies several nursing problems for an older adult client with gastroenteritis who is experiencing fever, chills, anorexia, and diarrhea.
The client has a history of a stroke with left-sided hemiplegia and is dependent on care provided by the spouse. Which problem should the nurse determine has the highest priority?