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?

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 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?

The nurse identifies an electrolyte imbalance, elevated blood pressure, and a weight gain of 4.4 lbs (2 kg) in 24 hours in a client with hepatic failure.
Which intervention should the nurse include in the plan of care?

A patient with neuroleptic malignant syndrome has been prescribed dantrolene 1.5 mg/kg IV. The patient weighs 132 pounds.

The label on the 250 mg vial reads, “Reconstitute with 5 mL sterile water for injection, USP. Reconstitution yields 50 mg/mL.”. How many mL should the nurse administer?

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?

The nurse observes an unlicensed assistive personnel (UAP) preparing to provide personal care for a patient who requires contact precautions. The UAP has put on a gown and gloves and has secured the tops of the gloves over the gown sleeves. What action should the nurse take?

The nurse is about to administer a histamine 2-receptor antagonist to a patient with peptic ulcer disease. What is the primary purpose of this class of medication?

A client on the cardiac telemetry unit suddenly starts showing signs of ventricular fibrillation. The advanced cardiac life support (ACLS) team defibrillates the client, restoring a normal sinus rhythm. Later in the day, a family member Questions why the code was called, telling the nurse that the client has a living will.
How should the nurse respond?

A patient with a history of adrenal insufficiency has been admitted to the intensive care unit due to an acute adrenal crisis.

The patient is experiencing nausea and joint pain.

The patient’s vital signs are as follows: temperature of 102 F (38.9° C), heart rate of 138 beats/minute, and blood pressure of 80/60 mm Hg. What is the first intervention the nurse should implement?

The nurse is educating a first-time pregnant woman about preeclampsia.
Which symptoms are indicators of preeclampsia and should be reported to the healthcare provider? Select all that apply.