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A nurse is caring for a client that has a nasogastric tube attached to suction. The tube was inserted in the right nare. During the initial assessment the nurse finds that the client is lethargic, has dry mucous membranes and the BP is 102/64, RR 16. The nurse sees that the IV is running at 50mL/hr. What is the nurse’s MOST appropriate initial response?  

A nurse is preparing to discharge a client hospitalized for an exacerbation of chronic gastritis. What health prevention should the nurse emphasize when reviewing the client’s discharge instructions?

The nurse is assessing a client who has had diabetes for 20 years. The client states they have been experiencing a tingling sensation in their feet. The nurse understands the client is developing which complication of diabetes? 

The nurse is conducting an initial shift assessment on their client. Ceftriaxone is infusing at 50mL/hr. into a client’s right forearm. The nurse assesses the IV and notices that the peripheral IV site is edematous. The nurse palpates the site and finds the skin cool. How should the nurse document this complication of IV therapy? 

A 35-year-old male client arrives to the Emergency Department (ED) with symptoms of nausea and vomiting with intermittent abdominal cramping. CT scan is positive for small bowel obstruction. In collaboration with the primary care provider, what intervention should the nurse prioritize?

The nurse received report on the clients admitted to the post-anesthesia care unit (PACU) within the past hour. Which client admitted to the PACU should the nurse prioritize to see FIRST?

The client with diabetes received 8 units of regular insulin and 12 units of NPH insulin at 0730. At 0930 the client reports having a headache, feeling shaky and nervous. What is the probable cause for this client’s signs and symptoms? 

A client who had a right side above the knee amputation is received on the post-surgical unit from the PACU. The initial nurse’s assessment was LOC; responsive, A&O x4, VS:  T 99.2, HR 78, RR 18, BP 136/82, the surgical dressing clean, dry, and intact. The nurse reassesses the client 20 minutes later to find the client lethargic, VS: T 99.2 HR 100 RR 20, BP 110/72 and the dressing is saturated with copious amount of blood. What should the nurse’s INITIAL action be? 

The client has a nasogastric tube that has been placed to drain the stomach contents by low intermittent suction. What is the nurse’s PRIORITY when caring for this client? 

The nurse observes that a client with Alzheimer’s disease has been trying to button their shirt for several minutes. The client is becoming increasingly agitated. What is the nurse’s MOST APPROPRIATE response?