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?

An unlicensed assistive personnel (UAP) reports that a client’s right hand and fingers spasm when taking the blood pressure using the same arm.
After confirming the presence of the spasms, which action should the nurse take?

The nurse uses the Modified Caregiver Strain Index (MCSI) and determines that the daughter is experiencing significant stress due to taking on her mother’s care.

The nurse plans to discuss ways to reduce caregiver stress with the daughter.

Select three statements that the nurse should include in the discussion.

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 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?

A client with a venous ulcer, which has not responded to intravenous vancomycin treatment and is discharging pus, has been admitted with a potential infection of Vancomycin-Resistant Enterococci (VRE). Which nursing interventions should be included in the care plan? 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 with chronic obstructive pulmonary disease (COPD) receives a prescription for chest physiotherapy (CPT) to help mobilize secretions.
Following the therapy, which finding indicates to the nurse that the intervention was effective?

A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line.

The abdominal dressing is no longer occlusive, and the IV insertion site is pink.

What intervention should the nurse implement?

A first-time pregnant woman at 36 weeks of gestation is admitted to the labor and delivery unit because her membranes ruptured 30 minutes ago.

The initial assessment indicates a 2 cm cervical dilation, 50% effacement, -2 station, vertex presentation, greenish- colored amniotic fluid, and contractions occurring every 3 to 5 minutes.

There is a decrease in fetal heart rate after the last four contraction peaks.

What should the nurse do first?

A 35-year-old woman, who works as a legal secretary, visits the outpatient clinic for an assessment of consistent pain in her hands.

She reports that the pain is identical in both hands and wrists but is worse upon waking. The pain and stiffness have persisted for the past 3 months.

She believes she has arthritis because her mother and grandmother both have arthritis.

Based on the data provided, determine the most likely condition the client is experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.