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.

The nurse is providing postoperative care for an adolescent who had a left leg amputation due to osteosarcoma and is experiencing phantom limb pain.
What non-pharmacological intervention should the nurse provide?

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 client on the mental health unit has been displaying signs of agitation, such as scowling and pacing rapidly up and down the hallway for several minutes.
Which behaviors should the nurse prioritize for monitoring?

The nurse is monitoring a patient with Cushing’s disease in the post-anesthesia care unit (PACU) following a hypophysectomy.
Which intervention is most important for the nurse to include in the patient’s plan of care?

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 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 adult client with severe depression was admitted to the psychiatric unit yesterday evening.

Despite having run a marathon a year ago, the client now spends most of the day sitting and watching television, according to the spouse.

What is the most important intervention for the nurse to include in this client’s care plan for today?

The primary caregiver of an elderly patient contacts the nurse at the outpatient clinic due to a sudden change in the patient’s behavior.

The caregiver informs the nurse that the patient, who is usually oriented and able to answer Questions, is now confused and agitated.

What actions should the nurse take? (Select all that apply)

A client with a right hemopneumothorax has a chest tube connected to suction.
While turning to the left side, the client becomes suddenly short of breath and anxious. What should the nurse do 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?