A patient with a history of heart failure presents at the emergency department reporting fatigue and weakness. The patient has been taking 50 mg spironolactone tablets orally every day.

The nurse receives a lab report indicating the patient’s serum potassium level is 6.2 mEq/L (6.2 mmol/L). What is the most important intervention for the nurse to implement?

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 49-year-old male patient has been experiencing flu-like symptoms, including fever and chest congestion, for the past four days.

He visited the emergency department (ED) last night due to increased difficulty in breathing.

The patient has a 20-year history of smoking half a pack of cigarettes per day and has no significant medical or surgical history.

The nurse has placed the patient on a cardiorespiratory monitor and administered a nasal cannula. After completing an assessment, the nurse documented the findings in the patient’s chart.

Which assessment findings indicate hypoxia?

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?

An older adult with a terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying.
What interventions should the nurse include in this client’s plan of care? Select all that apply.

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 client with a right hemopneumothorax has a chest tube connected to suction.
While turning to the left side, the client becomes suddenly short of breath and anxious. What should the nurse do next?

An adolescent arrives at the emergency department (ED) with a fever and persistent lower right quadrant abdominal pain.

The patient is anxious, fearful, and hyperventilating.

What acid-base imbalance does the nurse anticipate the patient will develop?

The nurse is preparing a dose of teriparatide for a patient.

The medication is labeled as “750 mcg/2.4 mL”. How many mL should the nurse administer to deliver a dose of 60 mcg

An older adult patient arrives at the clinic reporting decreased strength in knees and handgrips. What action should the nurse include in a functional assessment of this patient?

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?