Author: Anonymous

The nurse is caring for a client following a traumatic head injury.  The patient’s current vital signs are: T99.2F  HR 108  RR 24  BP 155/80.  The ICP is 26. No seizure activity is noted. Which of the following orders would the nurse carry out?

A client comes to the urgent care with complaints of abdominal pain radiating to his right shoulder.  When asked what activity preceded the pain the client stated he was just watching TV after having dinner out at a restaurant. When asked what he ate, he states, “A steak, baked potato with butter, salad, and a couple of glasses of wine”.  The vital signs are T 98.4F (36.9C), HR 99, RR 20, BP 138/72. The nurse would anticipate which of the following diagnostic labs or procedures to be ordered? 

The nurse is assessing a client admitted to the medical-surgical unit on the night shift. The nurse observes that the client has an enlarged, protruding abdomen and distended veins on the abdominal wall.  Upon physical examination, the nurse detects a shock wave of fluid during palpation and dullness to percussion.  The nurse notes the client is confused and exhibits asterixis. The nurse would anticipate the provider to order what intervention? 

A young man comes to the provider office with complaints of muscle weakness. lack of appetite, and weight loss. The nurse notes dark skin pigmentation as well. What would the nurse anticipate ordered by the provider?  Select all that apply

A client has been admitted to ICU with sepsis due to cellulitis of the leg. The provider ordered Ampicillin 600mg/75mL to run over 45 minutes. No pump can be found to infuse this and the tubing has a drop factor of 10 gtts/mL. How many gtts/min will the nurse infuse the medication at? (round to the nearest whole number) 

A nurse is caring for a client who has an epidural hematoma. Which of the following manifestations should the nurse expect?

A nurse is planning the care of a client who will be immunosuppressed as part of a bone marrow transplant protocol.  What is the most important component of infection control in the care of this client? 

Which intervention would a nurse include when creating a nursing plan for a client admitted with Graves disease. 

A  nurse is completing the suicide screening for a client brought to the emergency department by his wife. The client is not making eye contact, speaks in a low, flat tone, and states he is depressed. What priority question should the nurse ask to determine the client’s risk of harming himself? 

The nurse identifies that the client may be in the compensatory stage of shock.  What nursing assessment monitors for reduced tissue perfusion?