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?

Upon entering a patient’s room to administer an IV antibiotic at 0900, the nurse discovers that the patient is engaged in sexual activity with a visitor.
What should be the nurse’s course of action?

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?

The nurse is providing postoperative care for an adolescent who underwent a left leg amputation due to osteosarcoma.

The adolescent reports experiencing phantom limb pain.

Which non-pharmacological intervention should the nurse provide?

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

He hasn’t had a bowel movement in 7 days, his abdomen is distended, and he recently vomited 150 mL of dark brown emesis.

In what order should the nurse carry out the following interventions? Arrange from the highest to the lowest priority.

A client with gout in the left great toe has received a prescription for prednisone 30 mg by mouth to be administered each day.
Which symptom is most important for the client to report to the healthcare provider?

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 patient admitted to the hospital with a suspected ruptured diverticulum develops signs and symptoms of septic shock.

The healthcare provider prescribes a sepsis protocol.

Which intervention is most important for the nurse to include in the plan of care?

The nurse is reviewing laboratory results for a patient scheduled for a cholecystectomy. Which result is most important for the nurse to report to the surgeon?

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

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

The patient has a 20-year history of smoking half a pack of cigarettes per day and has no significant medical or surgical history.

The nurse has placed the patient on a cardiorespiratory monitor and administered a nasal cannula. After completing an assessment, the nurse documented the findings in the patient’s chart.

Which assessment findings indicate hypoxia?

A client with a deep vein thrombosis (DVT) in the left leg is on a heparin protocol. What is the most crucial intervention for the nurse to include in this client’s care plan?