A client is admitted to the emergency department (ED) with r…

A client is admitted to the emergency department (ED) with right sided facial droop, right sided paralysis, and slurred speech. The client’s daughter stated that the symptoms started 45 minutes ago. The patient has a blood glucose of 100. The client’s vital signs are temperature of 98.6 °F (37ºC), heart rate 76 beats/min, respiratory rate of 18 breaths/min, blood pressure 164/80, and SpO2 of 96% on room air. The CT of the head is negative. The nurse prepares to administer tissue plasminogen activator per provider order. What are the priority nursing interventions? (Select all that apply.)

The nurse admits a client to the critical care unit followin…

The nurse admits a client to the critical care unit following a motorcycle crash. Assessment findings by the nurse include blood pressure 120/64 mm Hg, heart rate 56 beats/min, respiratory rate 26 breaths/min, and temperature of 100.3°F (37.9ºC). The client is lethargic, responds to voice but falls asleep readily when not stimulated. Which nursing action is most important to include in this client’s plan of care?