Which assessment finding is most crucial when planning to provide a complete bed bath to a bedfast client?

A client who follows Mormon beliefs is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request for this client? Select all that apply.

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?

What intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.

An adolescent patient with a non-union of a comminuted fracture of the tibia is admitted with osteomyelitis.
After the healthcare provider collects bone aspirate specimens for culture and sensitivity and applies a cast to the adolescent’s lower leg, what should the nurse do next?

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?

A nurse notices clear fluid on the surgical dressing of a patient who has just returned from lumbar spinal surgery. What should be the nurse’s immediate course of action?

A client with a right hemopneumothorax has a chest tube connected to suction.
While turning to the left side, the client becomes suddenly short of breath and anxious. What should the nurse do next?

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?

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

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?