Mark whether the statements by the new graduate nurse indicate understanding or no understanding of the use of the face mask in the care of this client.

The nurse observes an unlicensed assistive personnel (UAP) preparing to provide personal care for a patient who requires contact precautions. The UAP has put on a gown and gloves and has secured the tops of the gloves over the gown sleeves. What action should the nurse take?

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.

A 35-year-old woman, who works as a legal secretary, visits the outpatient clinic for an assessment of consistent pain in her hands.

She reports that the pain is identical in both hands and wrists but is worse upon waking. The pain and stiffness have persisted for the past 3 months.

She believes she has arthritis because her mother and grandmother both have arthritis.

Based on the data provided, determine the most likely condition the client is experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

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 who follows Mormon beliefs is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request for this client? Select all that apply.

A primary caregiver of an older adult client calls the nurse at the outpatient clinic due to a sudden onset of changes in the client’s behavior.

The caregiver reports to the nurse that the client normally is oriented and able to answer Questions but now is confused.

What action(s) should the nurse take? Select all that apply.

The nurse is caring for a client with decompensated liver disease who is experiencing fever, chills, and abdominal tenderness.

Following a paracentesis, the nurse receives laboratory results of the ascitic fluid that show the polymorphonuclear leukocyte count is 425/mm (0.42 x 10/L). After notifying the healthcare provider, what action should the nurse take next?

A nurse is attending to a patient who suddenly experiences numbness and weakness on the right side of their body, including their arm and leg.

The nurse also observes a distinct droop on the right side of the patient’s 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?

The charge nurse is observing a new nurse who is preparing to insert an intravenous (IV) catheter.

The new nurse has gathered supplies including intravenous catheters, an intravenous insertion kit, and a 4x sterile gauze dressing to cover and secure the insertion.

What action should the charge nurse take?

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