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 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?

The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours.
Which additional action should the nurse instruct the UAP to take each time the client is turned?

A client with a history of gout comes to the clinic with an inflamed left knee. The client reports the knee is extremely painful to touch for the second time in 6 months. The healthcare provider prescribes colchicine and ibuprofen.
What instruction should the nurse include in the discharge teaching?

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?

A nurse in the emergency department is collecting evidence for a rape kit from a woman who reports that she was raped while returning to her dormitory from the university library.
Which intervention is most crucial for the nurse to implement?

What action should the school nurse take to provide secondary prevention for school-aged children?

The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem?

A patient is brought to the emergency department after falling from a ladder and is exhibiting signs of confusion and disorientation.

The spouse reports that the patient may have lost consciousness.

The nurse has been provided with a list of current medications and healthcare power of attorney.

When using SBAR (Situation, Background, Assessment, Recommendation) communication to report to the healthcare provider, which information should be provided first?

An adult patient with type 2 diabetes mellitus (DM2) is due to be admitted to the medical unit from the emergency department within the next hour.
The patient’s lab results show that the serum glucose is 175 mg/dL (9.63 mmol/L) and the A1c is 9%. Which meal option should the nurse request for the patient’s dinner tray?

An adolescent patient with a non-union of a comminuted fracture of the tibia is admitted with osteomyelitis.
After the healthcare provider collects bone aspirate specimens for culture and sensitivity and applies a cast to the adolescent’s lower leg, what should the nurse do next?