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A nurse is caring for a client who has sustained a spinal cord injury at the C5 level. Which of the following assessments should the nurse prioritize?

A nurse is assessing a client with end-stage kidney disease (ESKD) who missed their last two hemodialysis sessions. The client has gained 5 kg (11 lb.) in the past week and present with severe dyspnea, crackles in all lung fields, and 3+pitting edema. The morning laboratory results are as followings: potassium: 6.8 mEq/dL, BUN: 90 mg/dL, creatinine: 19.2 mg/dL, pH: 7.20, HCO3 (bicarbonate): 15 mEq/L. Which prescription should the nurse implement first?

A nurse is caring for a client with Guillain-Barré Syndrome (GBS) in the acute care unit. The client has weakness in the lower extremities but is alert and oriented. The nurse is implementing interventions to maximize respiratory function and prevent complications related to immobility. Which nursing intervention should be prioritized?

A client with DKA is receiving IV normal saline and an insulin drip. The nurse notes that the client’s serum potassium is now 2.8 mEq/L, and the client reports muscle weakness and palpitations. Which action should the nurse take first?

A nurse is caring for a client who is in the recovery phase of acute kidney failure. Which assessment finding would the nurse expect to observe during this phase?

A client with an acute ischemic stroke is admitted to the emergency department. The nurse reviews the following data: Blood pressure: 210/115 mm Hg, Heart rate: 92 bpm, SpO₂: 96% on room air, The client is not a candidate for fibrinolytic therapy.  Which action should the nurse anticipate taking?

A client arrives at the emergency department via EMS after falling from a horse and is unresponsive. The nurse notes that a cervical collar is in place. Which action should the nurse perform first?

After administration of IV lorazepam, the client’s seizure subsides, but respirations are shallow and O₂ saturation is 88%. Which action should the nurse take next?

A client with diabetic ketoacidosis (DKA) has a prescription for an insulin infusion at 0.1 units/kg/hr. The client weighs 155 lb (70.5 kg). The pharmacy has provided a premixed bag containing 100 units of regular insulin in 100 mL of normal saline. The primary nurse has programmed the infusion pump to deliver 10 mL/hr.What action should the charge nurse take next?

A client with diabetic ketoacidosis (DKA) was admitted to the intensive care unit 4 hours ago. The following laboratory results are available:Blood glucose level: 450 mg/dLSerum potassium level: 2.5 mEq/LSerum sodium level: 140 mEq/LUrine specific gravity: 1.025Total urine output (past 4 hours): 50 mLThe client has two IV lines infusing normal saline solution. The physician provides the following orders. Which provider order should the nurse question?