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?

A client is admitted for an exacerbation of heart failure (HF) and is being treated with diuretics for fluid volume excess.
In planning nursing care, which interventions should the nurse include? Select all that apply.

The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours.
What additional action should the nurse instruct the UAP to perform each time the client is turned?

The patient is a 75-year-old female who has been admitted to the preoperative area in preparation for pacemaker insertion.

She reports that she is undergoing this procedure because her heart rate has been consistently low, she feels constantly fatigued, and she has experienced one episode of fainting due to a low heart rate.

The patient has a history of progressively worsening symptomatic bradycardia and a history of atrial fibrillation, which is controlled by medication.

She has been off anticoagulants for four days in preparation for the procedure.

As the nurse prepares the patient’s plan of care, which four findings would indicate that it would be safe to administer the antibiotic vancomycin?

The nurse inspects the airway and finds no visible trauma, and the airway appears to be patent.
What other assessment items are included in the primary survey? Select all that apply.

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

The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents.
Which information is most important for the nurse to include?

A patient with pancreatic cancer develops ascites, and 2 liters of fluid are removed via paracentesis. What schedule should the nurse follow to monitor the patient’s blood pressure after this procedure?

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?

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

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