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.

Upon entering a patient’s room to administer an IV antibiotic at 0900, the nurse discovers that the patient is engaged in sexual activity with a visitor.
What should be the nurse’s course of action?

The nurse is educating a patient who was admitted with a blood glucose level of 580 mg/dL on how to prevent complications related to diabetes mellitus.
Which statement, if made by the patient, would indicate that they have understood the teaching?

The nurse is reviewing laboratory results for a patient scheduled for a cholecystectomy. Which result is most important for the nurse to report to the surgeon?

What intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.

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?

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?

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 client is a 55-year-old male who was admitted to the hospital 1 week ago for sepsis. The client has been intubated since admission.
Current ventilator settings are synchronized intermittent mandatory ventilation (SIMV) respiratory rate 15 breaths/minute, tidal volume (TV) 500 mL, fraction of inspired oxygen (FiO) 40%. Based on the client’s status at 1400, the nurse should plan to do which of the following?

A patient with a history of adrenal insufficiency has been admitted to the intensive care unit due to an acute adrenal crisis.

The patient is experiencing nausea and joint pain.

The patient’s vital signs are as follows: temperature of 102 F (38.9° C), heart rate of 138 beats/minute, and blood pressure of 80/60 mm Hg. What is the first intervention the nurse should implement?

A client with a history of heart failure arrives at the emergency department describing an onset of fatigue and weakness.

The client has been taking spironolactone 50 mg tablets PO every day.

The nurse receives a report from the lab that the client has a serum potassium level of 6.2 mEq/L (6.2 mmol/L). Which intervention is most important for the nurse to implement?