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 perform the following interventions? Arrange from highest to lowest priority.

The unlicensed assistive personnel (UAP) reports that a client’s blood pressure cannot be measured in the arms because the client has casts on both arms and is unable to be measured in the legs because the client is in the supine position.
Which action should the nurse implement?

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?

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

The nurse is providing postoperative care for an adolescent who underwent a left leg amputation due to osteosarcoma.

The adolescent reports experiencing phantom limb pain.

Which non-pharmacological intervention should the nurse provide?

A client with a history of gout comes to the clinic with an inflamed left knee. The client reports the knee is extremely painful to touch for the second time in 6 months. The healthcare provider prescribes colchicine and ibuprofen.
What instruction should the nurse include in the discharge teaching?

An adult client with severe depression was admitted to the psychiatric unit yesterday evening.

Despite having run a marathon a year ago, the client now spends most of the day sitting and watching television, according to the spouse.

What is the most important intervention for the nurse to include in this client’s care plan for today?

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 on the cardiac telemetry unit suddenly starts showing signs of ventricular fibrillation. The advanced cardiac life support (ACLS) team defibrillates the client, restoring a normal sinus rhythm. Later in the day, a family member Questions why the code was called, telling the nurse that the client has a living will.
How should the nurse respond?

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?

An adult patient with type 2 diabetes mellitus (DM2) is due to be admitted to the medical unit from the emergency department within the next hour.
The patient’s lab results show that the serum glucose is 175 mg/dL (9.63 mmol/L) and the A1c is 9%. Which meal option should the nurse request for the patient’s dinner tray?