The nurse is caring for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral issues. Which is the best initial nursing action?

A client with acquired immune deficiency syndrome (AIDS) and Pneumocystis jiroveci pneumonia has a CD4+ T cell count of 200 cells/mm³ (20%). The client asks the nurse why they have these recurring massive infections. Which pathophysiologic mechanism should the nurse describe in response to this client's question?

Reference Range:
T-helper CD4 cells [600 to 1500 cells/mm³ (60 to 75%)]

A 70-year-old female presents to the emergency department through triage with a noticeable facial droop and garbled speech. After having a few drinks at a local seafood restaurant, the client's husband noticed his wife's speech became difficult to understand.

Flow sheets

1915

Arrival at emergency department

1920

Vital Signs:

- Temperature: 98.2° F (36.8° C)

- Heart rate: 92 beats/minute

- Respirations: 24 breaths/minute

- Blood pressure: 210/98 mmHg

- Oxygen saturation: 95% on room air

Imaging studies

1935

Head CT scan results:

- No evidence of intracranial hemorrhage

- No evidence of acute disease

Orders

- Obtain CT scan of the head.

- Insert a large bore peripheral IV.

- Start normal saline infusion at 50 mL/hour.

• The nurse administered tPA and conducted neurologic assessments every 15 minutes during the infusion.
• The tPA infusion finished and the nurse performed neurologic assessments every 30 minutes for the 6 hours following the administration.
• The client was noted to be stable with unchanged neurologic assessments.
• The nurse begins to plan care for the client's recovery and identifies interdisciplinary team members who can assist with the client's recovery.

Select the interdisciplinary team members who should assist the client in recovery.

The nurse is caring for a client who had a cholecystectomy two days ago. The client is febrile, reporting upper abdominal pain radiating to the back and has had three episodes of vomiting in the last 8 hours. The nurse reviews the client's serum amylase and lipase level results which are twice the normal value. Based on these findings, the nurse should recognize the client is exhibiting symptoms of which condition?

For each assessment finding, explain whether the actions taken were effective or ineffective.

The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?

While completing a health assessment for a young adult female with acute appendicitis, the client informs the nurse that there is a chance that she may be pregnant. The operating team is preparing to take the client to surgery. Which intervention should the nurse implement immediately?

A client who had a biliopancreatic diversion procedure (BPD) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse?

Specify which potential condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s response.