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?

Which assessment finding is most crucial when planning to provide a complete bed bath to a bedfast client?

The nurse notices redness under the chin of a client who is receiving oxygen at 2 L/minute via a nasal cannula. What action should the nurse take?

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?

A 49-year-old male patient has been experiencing flu-like symptoms, including fever and chest congestion, for the past 4 days.

He visited the emergency department (ED) last night due to increased difficulty in breathing.

He has a history of smoking half a pack of cigarettes daily for 20 years, but no significant medical or surgical history.

If the healthcare provider orders the patient to be put on oxygen, which items should the nurse collect from the supply room? (Select all that apply)

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 who weighs 176 pounds is prescribed enoxaparin sodium 1.5 mg/kg/day subcutaneously. The medication is available in a 120 mg/0.8 mL prefilled syringe.

How many mL should the nurse administer? (Enter numerical value only.)

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)

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 elderly male patient, who has been experiencing abdominal pain, is admitted to the hospital from a long-term care facility.

It has been a week since his last bowel movement, his abdomen is distended, and he recently vomited 150 mL of dark brown emesis.

In what order should the nurse implement the following interventions? Arrange from the highest priority at the top to the lowest at the bottom.

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?