When entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which action should the nurse implement?

A client experiencing withdrawal from the benzodiazepine alprazolam is demonstrating severe agitation and tremors. Which is the best initial nursing action?

The nurse is providing discharge instructions to a client with gout in the left great toe who received a prescription for prednisone 30 mg by mouth to be administered each day. Which symptom should the nurse explain is most important for the client to report to the healthcare provider?

An older adult with a terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying. What intervention(s) should the nurse include in this client's plan of care? Select all that apply.

The nurse identifies several nursing problems for an older adult client with gastroenteritis who is experiencing fever, chills, anorexia, and diarrhea. The client has a history of a stroke with left-sided hemiplegia and is dependent on care provided by the spouse. Which problem should the nurse determine has the highest priority?

An adolescent who is brought to the emergency department (ED) with a fever and persistent lower right quadrant abdominal pain is anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid-base imbalance?

Prior to insertion of an indwelling urinary catheter, which client information is most important for the nurse to obtain?

The nurse is collecting a heelstick blood specimen for a neonatal screen, which includes thyroxine (T4) and thyroid stimulating hormone (TSH) levels, prior to the discharge of a 2-day- old client. When the parents ask why these tests are being conducted, which explanation should the nurse provide?

Highlight the 3 orders that should be completed first.

Orders

• Administer oxygen 5 L/minute via simple face mask
• Vital signs ever 1 hour
• X-ray of the right arm and cervical spin
• Place 2 large bore peripheral IV's
• Computed tomography scan of the brain
• Give 1 Liter bolus of 0.9% sodium chloride solution IV once
• Bacitracin applied topically to lacerations every 12 hours

An adult client with type 2 diabetes mellitus (DM2) is to be admitted within the next hour to the medical unit from the emergency department. The client's laboratory findings indicate that

the serum glucose is 175 mg/dL (9.63 mmol/L) and the A1c is 9%. 
When requesting a dinner tray for the client, which menu should the nurse select?

Reference Ranges:

Blood glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)] HbA1C [Good diabetic control: less than 7%]

The nurse is teaching a primigravida about preeclampsia. What finding(s) are indicators of preeclampsia and should be reported to the healthcare provider? Select all that apply.