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 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?

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?

An adult patient with type 2 diabetes mellitus (DM2) is due to be admitted to the medical unit from the emergency department within the next hour.
The patient’s lab results show that the serum glucose is 175 mg/dL (9.63 mmol/L) and the A1c is 9%. Which meal option should the nurse request for the patient’s dinner tray?

A client with neuroleptic malignant syndrome receives a prescription for dantrolene 1.5 mg/kg IV. The client 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 child with an Escherichia coli urinary tract infection is receiving a secondary infusion of gentamicin 60 mg every 8 hours IV, which is to be infused over 30 minutes.

The medication is delivered by the pharmacy diluted in a 50 ml bag of saline.

What should be the infusion pump’s regulation in mL/hour? (Provide the numeric value only.)

A client is admitted for an exacerbation of heart failure (HF) and is being treated with diuretics for fluid volume excess.
In planning nursing care, which interventions should the nurse include? Select all that apply.

A nurse is caring for a patient who suddenly experiences right-sided numbness and weakness in the arm and leg, along with a distinct droop on the right side of the face.

After reporting these findings to the healthcare provider, the nurse receives several prescriptions for the patient, including an immediate CT scan of the head.

What should be the nurse’s first course of action?

A 49-year-old male patient has been experiencing flu-like symptoms, including fever and chest congestion, for the past 4 days.

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

He has a history of smoking half a pack of cigarettes daily for 20 years, but no significant medical or surgical history.

If the healthcare provider orders the patient to be put on oxygen, which items should the nurse collect from the supply room? (Select all that apply)

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

The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours.
What additional action should the nurse instruct the UAP to perform each time the client is turned?