Author: Anonymous

The nurse is caring for a client admitted to the ED following a fall from a 10-foot ladder. Upon admission, the nurse assesses the client to be awake, alert, and moving all four extremities. The nurse also notes bruising behind the left ear and straw-colored drainage from the left nare. Which of the following is the most appropriate nursing action?

The nurse has obtained the following Arterial Blood Gas (ABG) reading from the client: pH 7.30, CO2 63, HCO3 26, PaO2 92% The nurse would anticipate that this reading is a result of which of the following conditions?  

The client with acute pancreatitis is started on total parenteral nutrition (TPN). The student nurse listed possible interventions for this patient. Which of the following interventions needs correction by the nurse before finalizing the plan of care?

The nurse has obtained the following Arterial Blood Gas (ABG) reading from the client: pH 7.30, CO2 63, HCO3 26, PaO2 92% The nurse would anticipate that this reading is a result of which of the following conditions?  

The picture below represents the the femur fracture that was sustained by the client following a motor vehicle accident: The client’s vital signs are: B/P 98/50 mmHg, Pulse 130 BPM, RR 24, Temp 37.5C, Pain 10 (0-10 scale). The nurse know that the client is at risk for which of the following? Select all that apply.

CASE STUDY QUESTION   The following questions pertain to the client who is newly admitted in the ICU with diabetic ketoacidosis.   Which of the following lab values would indicate that this client has achieved long term effective management of their Diabetes after being discharged?

A client is admitted with a large right tension pneumothorax after a ski pole fell on them and created a sucking chest wound. Which of the following findings would best confirm the presence of a tension pneumothorax?

The nurse is caring for the client with cerebral edema with a Glasgow Coma Scale (GCS) of 5 and an intracerebral pressure reading (ICP) of 21 mm/Hg. Which of the following medications ordered by the healthcare provider would be inappropriate to administer to the client?

An acutely ill client is being cared for in the critical care unit. The client is delirious and is exhibiting signs of significant anxiety. The nurse should recognize that the client is at greatest risk for which of the following nursing diagnosis?

The client is diagnosed with mitral stenosis and new-onset atrial fibrillation. Which of the following interventions could the nurse delegate to the unlicensed assistive personnel? Select all that apply.