The nurse is implementing the plan of care for a client.

For each body system, identify the potential nursing intervention that would be appropriate for the care of the client. Each body system may support more than one potential nursing intervention.

Each category must have at least one response option selected.

A 10-year-old child with pneumonia is receiving oxygen at 5 L/minute via a nasal cannula.
When planning care for this child, what principle of oxygen administration should the nurse keep in mind?

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 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 client with neuroleptic malignant syndrome receives a prescription for dantrolene 1.5 mg/kg IV. The client weighs 132 pounds.

The label on the 250 mg vial reads, “Reconstitute with 5 mL sterile water for injection, USP. Reconstitution yields 50 mg/mL.”. How many mL should the nurse administer?

The nurse inspects the airway and finds no visible trauma, and the airway appears to be patent.
What other assessment items are included in the primary survey? Select all that apply.

An older adult patient arrives at the clinic reporting decreased strength in knees and handgrips. What action should the nurse include in a functional assessment of this patient?

A patient with a history of heart failure presents at the emergency department reporting fatigue and weakness. The patient has been taking 50 mg spironolactone tablets orally every day.

The nurse receives a lab report indicating the patient’s serum potassium level is 6.2 mEq/L (6.2 mmol/L). What is the most important intervention for the nurse to implement?

A patient with diabetic peripheral neuropathy has been taking pregabalin for the past four days. Which finding would indicate to the nurse that the medication is effective?

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?

Which intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an intravenous (IV) site in the client’s arm?