A mother rushes into the emergency department carrying her toddler who has been exposed to some cleaning products.

The child has a chemical smell on their hands, face, and clothes.
After ensuring the airway is patent, which action should the nurse take first?

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 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?

A nurse in the emergency department is collecting evidence for a rape kit from a woman who reports that she was raped while returning to her dormitory from the university library.
Which intervention is most crucial for the nurse to implement?

Upon entering a patient’s room to administer an IV antibiotic at 0900, the nurse discovers that the patient is engaged in sexual activity with a visitor.
What should be the nurse’s course of action?

A client who weighs 176 pounds is prescribed enoxaparin sodium 1.5 mg/kg/day subcutaneously. The medication is available in a 120 mg/0.8 mL prefilled syringe.

How many mL should the nurse administer? (Enter numerical value only.)

A first-time pregnant woman at 36 weeks of gestation is admitted to the labor and delivery unit because her membranes ruptured 30 minutes ago.

The initial assessment indicates a 2 cm cervical dilation, 50% effacement, -2 station, vertex presentation, greenish- colored amniotic fluid, and contractions occurring every 3 to 5 minutes.

There is a decrease in fetal heart rate after the last four contraction peaks.

What should the nurse do first?

The nurse notices redness under the chin of a client who is receiving oxygen at 2 L/minute via a nasal cannula. What action should the nurse take?

A client with chronic obstructive pulmonary disease (COPD) receives a prescription for chest physiotherapy (CPT) to help mobilize secretions.
Following the therapy, which finding indicates to the nurse that the intervention was effective?

Restricted activity is prescribed for a client with Crohn’s disease. What is the primary purpose of the activity restriction?

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.