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A nurse is caring for a client in the emergency department (ED). Nurses’ note:  0800: Client brought to ED by ambulance from long-term care facility. According to report from long-term care facility RN, client is normally alert but awoke this am disoriented to time and place, febrile, and incontinent of foul-smelling urine.  0815: Provider at bedside, prescriptions received. Vital signs:  0800: Temperature 37.3° C (99.2° F) Pulse 102/min Respirations 20/min Blood pressure 130/82 mm Hg Oxygen Saturation 95% on room air Physical examination:  0830: Client disoriented to time and place. Agitated. Attempting to get out of bed. Sinus tachycardia. Lung sounds clear. Bowel sounds x 4 normoactive. Incontinent of urine. Plan: Admit for observation Fall precautions Begin broad-spectrum antibiotic  Administer Acetaminophen (Tylenol) PO for temperature greater than 38° C (100.4° F)  Complete blood count Straight catheterization to obtain a urine specimen for urinalysis and culture and sensitivity (C&S). The nurse should first address the client’s (1.__________), followed by the client’s (2.________).  Complete the sentence above by selecting the answer best associated with the first priority followed by the best associated with the second priority. Answer choices with a #1 next to them indicate the options for first priority, and answer choices with a #2 next to them indicate the options for second priority. Only one answer with a #1 and one answer with a #2 should be selected. 

A nurse is caring for a 44-year-old client who was admitted with an elevated temperature and abdominal pain.  Medical history: The client reports “not feeling well” for 3 days. The client reports decreased appetite and generalized abdominal pain with nausea. No reports of vomiting or diarrhea. The client has a history of stage IV chronic kidney disease. The client’s baseline BUN with treatment is about 32 mg/dL, and creatinine is 3.0 mg/dL per nephrologist. The client currently completes continuous ambulatory peritoneal dialysis (CAPD) four times per day. The client lives alone and has 4 cats. Other pertinent history includes hypertension, diabetes, and neuropathy. The client has been noncompliant with health care provider visits and follow-up. Nurse’s Notes: 1000:   Admitted from the clinic with generalized abdominal pain. Reports pain as an 8 on a scale of 0 to 10. Generalized abdominal tenderness was noted upon palpation. Abdomen distended and rigid with decreased bowel sounds. Reports nausea but denies vomiting. Heart sounds distant and irregular. Respirations are labored with crackles throughout lung fields. Skin pale and cool with poor skin turgor.  3+ pitting edema on bilateral lower extremities. The client states they have not completed any dialysis for the past 24 hours due to weakness.  Vital signs: Temporal temperature 38.9º C (102º F)  Pulse 110 /min; irregular  Respirations 28/min; labored  Blood pressure 108/60 mm Hg right arm  Oxygen saturation 95% on room air  Diagnostic results: CBC                        Results                    Reference range RBC count 4.0/mm3 4.2 to 6.1/mm3 WBC count 17,000/mm3 5,000 to 10,000/mm3     Hgb 10 g/dL 12 to 18 g/dL Hct 20% 37% to 52% Platelets 160,000/mm3 150,000 to 400,000/mm3 Basic Metabolic Profile BUN 34 mg/dL 10 to 20 mg/dL Creatinine 3.0 mg/dL 0.5 to 1.3 mg/dL Total calcium 7 mg/dL 9.0 to 10.5 mg/dL Carbon dioxide 25 mEq/L 23 to 30 mEq/L Chloride 101 mEq/L 98 to 106 mEq/L Glucose 185 mg/dL 74 to 106 mg/dL Potassium 7.0 mEq/L 3.5 to 5 mEq/L Sodium 140 mEq/L 136 to 145 mEq/L Select the 5 client findings that require immediate follow-up.

Which clinical manifestation of acute pancreatitis would be the nurse’s highest priority?

A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy via a nasal cannula. Which of the following should the nurse include in the teaching? Select all that apply. 

The nurse is caring for a patient who is on an insulin drip for diabetic ketoacidosis (DKA). The patient’s blood sugar 1 hour ago was 300 mg/dL. The patient’s blood sugar is now 239 mg/dL (reference: 70-140 mg/dL). Which of the following intravenous fluids would the nurse anticipate giving the patient at this time?

A client is prescribed nitrofurantoin (Macrobid) for treatment of a lower urinary tract infection (UTI).  Select the 2 statements the nurse should include when teaching the patient. 

The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically with this disorder?

A student nurse is assigned to perform assessments of two patients with diabetes. Assessments reveal all of these findings. Which finding by the student nurse should be reported immediately?

Which procedure is most commonly used to treat cholecystitis?

Which of the following is a prerenal cause of acute kidney injury (AKI)?