Exhibits

Based on the assessment and blood gas results, which 3 orders should the nurse expect from the healthcare provider?

A client presents to the emergency department (ED reporting abdominal pain. The nurse observes the client's right cheek and eye are bruised and suspects possible domestic violence. Which approach is best for the nurse to use when interviewing the client?

Twenty minutes after the onset of symptoms, an adult client presents to the emergency department with slurred speech and right-sided weakness. After a computerized tomography (CT) scan reveals a non-hemorrhagic stroke, the nurse administers alteplase. Which assessment finding warrants immediate intervention?

A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a "Do Not Resuscitate" prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side to side as previously scheduled. Which action should the nurse take?

A client has a prescription for the insertion of a nasogastric tube to low intermittent suction. When inserting the nasogastric tube, the nurse observes an immediate return of "coffee ground" drainage. Which action should the nurse implement?

When admitting a client with a diagnosis of transient ischemic attack (TIA, which intervention is most important for the nurse to include in this client's plan of care?

The nurse is developing a plan of care for a client who reports chest pain on exertion and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?

The nurse places an opioid patch on the chest of a client with intractable pain who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client?

A client with osteomyelitis from a compound fracture of the left tibia has an open draining wound and is admitted with possible methicillin-resistant Staphylococcus aureus (MRSA infection. What intervention(s) should the nurse include in the plan of care? Select all that apply.

The nurse reviews the post catheterization orders. Which two orders would the nurse question?

An older adult client with a history of heart failure is admitted to the medical unit after falling at home and has become increasingly confused. The client's spouse is designated as the client's power of attorney. When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?