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An 82-year-old male client had emergency surgery this morning. The nurse performs the postoperative assessment and recognizes that he is at risk for delirium. Which of the following factors place the client at high risk for delirium? Select all that apply. 

A nurse in the emergency department is caring for a patient who had eaten shellfish and is now wheezing. What medication will the nurse anticipate being ordered?

Identify the order of steps for hand hygiene. 

Question A nurse walks into a client’s room and finds the client having difficulty breathing and complaining of chest pain. The client has bradycardia and hypotension. What should the nurse do next?

Nursing Notes 1905: Unlicensed assistive personnel (UAP) states that they found client on the floor in a pool of fluid and the client stated, “I tried to get to the bathroom and fell.” The client probably fell because they day shift nurse refused to answer the call light so close to the end of their shift. Client assessed and no injuries found. Assisted to the bathroom and back to bed. UAP gave client a bath. Client resting comfortably in bed. Call light within reach. Health care provider notified.1945: Client denies pain and discomfort. Continue to monitor.2100: Assisted client to bedside commode. Client voided 300 mL clear urine. Client was thirsty and drank a cup of water. Assisted back to bed. Resting comfortably. Vital Signs Time Blood Pressure Heart Rate Respiratory Rate Temperature SpO2 1800 125/80 89 16 98.9 F37.2 C 96% RA 1905 118/74 95 18 98.9 F37.2 C 96% RA Intake and Output 1000 1300 1800         2100 Oral Intake 100 mL 250 mL 250 mL 250 mL Urine Output -350 mL -300 mL Bowel Movement x 1             Question:  A team of clinical nurse specialists conducts audits of electronic health records (EHRs). When reviewing this client’s EHR, what piece of documentation do the nurses find most concerning?

When assisting a client from the bed into a wheelchair, the nurse notices the client is weak, unsteady, and complains of feeling faint. What would be the initial nursing intervention in this situation.

A nurse is assessing a client with hypertension. Which assessment findings should the nurse document as objective data? Select all that apply.

A nurse is assisting a client with dementia. What guideline is recommended when bathing this client?

A client arrives in the emergency department. The client is obese and having difficulty walking and breathing. What is the nurse’s priority assessment? 

The female nurse is providing a partial bed bath for a male client who has an uncircumcised penis. The client is not ambulatory, but does have full function of arms and hands. Identify the nurse’s most appropriate action.