A nurse is caring for a client who came to the emergency dep…

A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. The client is reporting discomfort and a feeling of bloating. Which of the following actions is the nurse’s priority?

An older adult male client is admitted to the cardiac ICU af…

An older adult male client is admitted to the cardiac ICU after suffering a heart attack. Upon taking a history after the client is stable, the nurse charts that he weighs over 275 pounds, has a history of heart disease in his family, suffers frequent stress at work, drinks alcohol daily, and smokes two packs of cigarettes daily. What are some modifiable risks factors for this client that has attributed to his heart attack? Select all that apply.

A nurse assesses a terminally ill patient with a DNR order,…

A nurse assesses a terminally ill patient with a DNR order, with findings of decreased blood pressure, urinary and bowel incontinence, loss of reflexes, agitation and Cheyne-Stokes respirations. Based on these findings, the nurse recognizes which of the following?

A nurse is caring for an older adult client in the emergency…

A nurse is caring for an older adult client in the emergency department. Which of the following findings require immediate follow-up? Select all that apply. Current vital signs: Temperature 39.3° C (102.8° F) Heart rate 93/min Respiratory rate 24/min Blood pressure 88/58 mm Hg Oxygen saturation 95% on room air Medical History: Older adult client, lives with family. Family states the client is normally alert and oriented but began to display confusion over the last 6 hr and has a new onset of incontinence. Client reports dizziness and constant low back and flank pain. Urinalysis: Appearance: cloudy                                                 Color: dark amber                                                    Odor: foul                                                                  pH: 8.0                                                                      Protein: 6.5 mg/dL                                                  Specific gravity: 1.035                                            Leukocyte esterase: positive                                 Nitrates: present                                                   Ketones: none                                                         Glucose: none                                                         White blood cells: 8                                            Red blood cells:  1