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 caring for a client with heart failure.
Which of these prescribed medications places the client at risk for cardiogenic shock?

The patient provides three positive responses to items on the CAGE (Cut down, Annoyed, Guilty, Eye-opener) query.
What interpretation should the nurse provide to the patient?

The nurse is caring for a client with a history of coronary artery disease who reports waking up with a sudden onset of vise-like chest pressure.

The client reports that the pain decreases at rest but continues to feel a constant mid-chest pressure. What intervention should the nurse perform in the immediate management of the client?

What intervention should the nurse perform in the immediate management of the client?

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?

While conducting an admission assessment of a female client with bipolar disorder, the client suddenly starts to undress and throw her clothes around the room.
What should be the nurse’s initial action?

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

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?

The nurse is developing the plan of care for a client diagnosed with Cushing’s syndrome and identifies that the client’s risk factors include poor wound healing, decreased bone density, and increased capillary fragility.
Which outcome statement should the nurse include in the plan of care?

A client is experiencing severe agitation and tremors due to withdrawal from the benzodiazepine alprazolam. What is the best initial nursing action?

A client with atrial fibrillation is scheduled for an elective cardioversion.

The nurse prepares for the procedure by inserting two intravenous (IV) catheters and connecting the monitoring lead wires to the client.
Which action is most crucial for the nurse to take before initiating the cardioversion?