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At 4:45 p.m., a nurse assesses a client with diabetes mellitus who is recovering from an abdominal hysterectomy 2 days ago. The nurse notes that the client is confused and diaphoretic. The nurse reviews the assessment data provided in the chart below:Capillary Blood Glucose Testing (AC/HS)Dietary IntakeAt 0630: 95At 1130: 70At 1630: 47Breakfast: 10% eaten – client states she is not hungryLunch: 5% eaten – client is nauseous; vomits onceAfter reviewing the client’s assessment data, which action is appropriate at this time?

A client with a history of acute coronary syndrome (myocardial infarction) is found restless and diaphoretic during the night. Review the clinical data and select the most appropriate nursing actions to prioritize care and ensure safety. Clinical Data: History: Acute coronary syndrome, hypertension, Type 2 diabetes Current Status: Restless, diaphoretic, reports mild chest discomfort Vital Signs: Blood Pressure: 140/92 mmHg Heart Rate: 108 bpm (irregular) Respiratory Rate: 24/min Oxygen Saturation: 94% on room air Current Medications: Aspirin 81 mg daily, Metoprolol 25 mg BID, Nitroglycerin PRN for chest pain Select the appropriate nursing actions to include in the plan of care: Select all that apply.

A registered nurse (RN) is delegating tasks to a licensed practical nurse (LPN) and a certified nursing assistant (CNA). Which statement by the RN demonstrates an appropriate delegation to the CNA, based on scope of practice?

An infant, three weeks old, is admitted to the Emergency Room. The mother reports that the infant has been irritable, difficult to breastfeed and has had diarrhea for the past 4 days. The infant’s respiratory rate is elevated and the fontanels are sunken. The Emergency Room physician orders ABGs after assessing the ABCs.The results from the ABGs come back from the laboratory and show:    pH = 7.37    Pa C02 = 29 mmHg    HC03 = 17 mEq/L What is your interpretion of the ABG results?

The nurse is creating a plan of care to prepare a 56-year-old male patient with ascites for a paracentesis. Which interventions should the nurse include to prep the patient and reduce the risk of complications? (Select all that apply)

The nurse is assessing a patient who sustained a traumatic brain injury. Using the Glasgow Coma Scale (GCS), match each observed patient response with the appropriate GCS component and score.

The nurse received an aPTT report on a client receiving heparin via continuous drip infusion. According to the report, the client’s drip rate should be decreased by 100 units per hour. The heparin comes prepared as 25,000 units in 500 mL of fluid. The current rate of infusion is 26 mL per hour. At what rate should the nurse set the pump?

A client in the immediate postoperative period has the following arterial blood gas (ABG) values: pH: 7.30 PaCO2: 52 mm Hg PaO2: 98 mm Hg HCO3: 22 mEq/L (22 mmol/L) As the nurse, develop a comprehensive plan of care to address the client’s ABG findings and prevent further complications. Prioritize the actions to be implemented immediately. Select all that apply:

A client with a diagnosis of acute coronary syndrome is on a cardiac monitor. The nurse interprets the monitor rhythm to be supraventricular tachycardia at a rate of 150 beats/min. The client is awake and coherent, and oxygen is being administered at a rate of 6 L/min via a nasal cannula. What is the first nursing action?

The nurse understands clamping a chest tube may cause what problem?