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 client with diabetic ketoacidosis (DKA) is receiving an IV infusion of 0.9% sodium chloride and insulin.
Two hours later, the client’s serum laboratory results show a decrease in the serum blood glucose from 580 to 430 mg/dL (32.2 to 23.86 mmol/L). What additional laboratory result is most important for the nurse to monitor?

A client with end-stage Alzheimer’s disease is brought to the clinic by the caregiver for an appointment with the healthcare provider.

The caregiver speaks privately to the nurse about not sleeping well at night and experiencing frequent periods of crying.

Which intervention should the nurse implement?

A client is experiencing severe agitation and tremors due to withdrawal from the benzodiazepine alprazolam. What is the best initial nursing 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?

A caregiver brings a client with end-stage Alzheimer’s disease to the clinic for an appointment with the healthcare provider.

The caregiver confides in the nurse about experiencing sleepless nights and frequent bouts of crying.

What action should the nurse take?

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 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?

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?

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?

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.