A family brought their 3-week-old infant to the hospital by ambulance after having a seizure at home.

The baby received phenytoin in the ambulance and arrived at the hospital on 1 L/minute oxygen with a 22-gauge peripheral IV line in the left saphenous vein.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

The nurse identifies an electrolyte imbalance, elevated blood pressure, and a weight gain of 4.4 lbs (2 kg) in 24 hours in a client with hepatic failure.
Which intervention should the nurse include in the plan of care?

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 nurse is caring for a client with heart failure.
Which of these prescribed medications places the client at risk for cardiogenic shock?

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

The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem?

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.

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 carry out the following interventions? Arrange from the highest to the lowest priority.

Which laboratory test results should the nurse monitor in a patient who has end-stage renal disease (ESRD)?

The patient is a 49-year-old male who has been experiencing flu-like symptoms, including fever and chest congestion, for 4 days.

He came to the emergency department (ED) last night when his breathing difficulties increased. He has a history of smoking half a pack of cigarettes a day for 20 years.

He has no significant medical or surgical history.

Which two orders should the nurse prioritize?

An elderly male patient, who has been experiencing abdominal pain, is admitted to the hospital from a long-term care facility.

It has been a week since his last bowel movement, his abdomen is distended, and he recently vomited 150 mL of dark brown emesis.

In what order should the nurse implement the following interventions? Arrange from the highest priority at the top to the lowest at the bottom.