An older female adult who was admited to a long-term care facility yesterday is confused about what day of the week it is. Her history does not indicate that she was confused prior to admission. What action should the practical nurse (PN) take?

The practical nurse (PN) is caring for a client with coronary artery disease who is admitted with intermittent chest pain. The admission laboratory results indicate elevations in troponin I and creatine phosphokinase myoglobin isoenzyme (CK-MB) levels.

What should the PN consider the most significant risk for this client on the second day of admission?

A client is receiving IV heparin and oral warfarin after a pulmonary embolism (PE). The nurse determines the client's activated partial prothromboplastin time (APTT) value is two times the control value; the prothrombin time (PT) level is the same as the control, and the international normalized ratio (INR) is 1. Which protocol prescription should the nurse implement?

Reference Range:

Activated Partial Prothromboplastin Time (APTT) [Anticoagulant therapy: 1.5 to 2 times the control value in seconds.] Prothromboplastin Time (PT) [Anticoagulant therapy: greater than 1.5 to 2 times the control value.] International Normalized Ratio (INR) [0.8 to 1.1]

The practical nurse (PN) is observing a newly hired PN who is preparing to administer a liquid medication via a client's feeding tube system as seen in the picture. What action should the PN take?

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA), which is the most important action for the nurse to take?

Patient Data

Which are the nurse's best responses? Select all that apply.

The nurse is caring for a client who reports a sudden, severe headache, and facial numbness.The nurse asks the client to smile and observes an uneven smile with a facial droop to the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headaches or trauma. After obtaining vital signs, the nurse should implement which intervention?

Find patient data below.

What actions should the nurse plan for the rest of the shift? Select all that apply.

A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare?

The client is a 32-year-old multigravida at 28 weeks' gestation, who presents to the obstetrician's office for a routine prenatal visit. Obstetrical history reveals she has given birth three times; once at 35 weeks (twins), once at 38 weeks (singleton), and once at 41 weeks (singleton). All of these children are alive and well. She had one spontaneous abortion at 10 weeks' gestation. Her fourth child weighed 9 pounds (4.08 kg) at 41 weeks gestation.

The client is at 28 weeks. She has been receiving prenatal care since 8 weeks gestation. Her fasting 1-hour glucose screening level, which was done 1 week prior, is 164 mg/dl (9.1 mmol/L). Her 3-hour oral glucose tolerance test results reveal a fasting blood sugar of 168 mg/dL (9.3 mmol/L) and a two-hour postprandial of 220 mg/dL (12.2 mmol/L).

The nurse reviews nurses' notes to determine what the client's obstetric history reveals in the form of GTPAL.

Choose the most likely option for the information missing from the statement by selecting from the list of options provided.

Based on the client's obstetrical history, the client's G-T-P-A-L designation is

The charge nurse brings a #18 urinary catheter with a 30 mL balloon to the practical nurse (PN) who is preparing to insert a catheter in a female client who weighs 50 kg. Which action should the PN take first?