The nurse is triaging several children as they present to the emergency room after a school bus accident. Which child requires the most immediate intervention by the nurse?

An older client comes to the clinic with a family member. When the nurse attempts to take the client's health history, the client does not respond to questions in a clear manner. Which action should the nurse implement first?

A client is admitted to the surgical intensive care unit following the removal of a large portion of the intestines due to a gunshot wound to the abdomen. The client begins to display signs of septic shock and a sepsis protocol is initiated. Which intervention is most important for the nurse to include in the plan of care?

The nurse at the 9-month visit reviews the child's height, weight, and feeding progression history.

What should the nurse advise the parents concerning the child's nutrition? Select all that apply

Exhibits

For each client statement, click to highlight the statement(s) below that require follow up teaching by the nurse.

"I am at high risk for post-traumatic-stress disorder because I have acute stress"

"I can use holistic approaches like meditation to help my symptoms." 

"I can learn to manage my thoughts better through therapy." 

"Many people have the same response to a stressful situation as I am having"

"This diagnosis means that I am crazy." 

"I will probably need to be on medication for the rest of my life." 

When planning care for an adolescent with anorexia nervosa, which nursing problem has the highest priority?

In planning care for a client with early stage Alzheimer's disease, the nurse establishes the nursing problem of risk for injury related to impaired judgment. Which intervention is most important for the nurse to include in this client's plan of care?

The healthcare provider prescribes 5% Dextrose Injection, USP with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care?

Reference Range

• Potassium [Reference Range: 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]
• Glucose [Reference Range: 0 to 50 years: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

Following morning care, a client with a C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implementfirst?

A client with unilateral hearing loss is admitted for a scheduled surgery. Which technique should the nurse use to provide education about pain relief options?

A client whose hyperthyroidism has not been responsive to medications is admitted for evaluation. During the admission assessment the client reports to the nurse of a sudden onset of feeling apprehensive and nurse notes the client is restless and very warm to touch. Which action should the nurse implement next?