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A nurse has identified “ineffective airway clearance” as a major nursing diagnosis for a client with pneumonia.  Which intervention for cough enhancement is appropriate to delegate to a nursing assistant?

A client presents in the emergency room reporting a headache, blurred vision, with a blood pressure of 220/118.  The client is admitted to the intensive care unit for the initiation and titration of an intravenous vasodilator, nicardipine hydrochloride. One hour after the initiation of nicardipine the client reports no headache and vision has return to normal.  The most recent blood pressure is 176/89.  The most appropriate action by the nurse is to

Which of the following factors increase oxygen demand in the client with multi-organ dysfunction syndrome (MODS)? Select all that apply.  

A 25 year old client has third degree burns over 50% of his lower body. He is recovering in stable condition.  The best snack for him would be:

A client who has been hospitalized with sepsis and has been on bed rest for 7 days develops a heart rate of 150, respiration 46, B/P 100/60, and becomes restless and anxious.  What is the appropriate nursing action?

A client is receiving fluid replacement after 35% of his body was burned 24 hours ago. Nursing assessment reveals a blood pressure of 86/60, pulse of 120, and urine output of 25 cc for the past hour. The nurse reports these findings to the primary care provider, anticipating orders to:

An emergency room nurse is assessing a 60-year-old female client who looks disheveled and angry.  As the nurse starts to get her vitals the woman accuses the nurse of “hurrying” and “not attending to her needs”.  What should the nurse do next?

Interpret the following arterial blood gas:             pH: 7.43, pCO2: 53, pO2: 76 HCO3: 30   

  Which instruction should a nurse give to a client with diabetes mellitus when teaching about “sick day rules”?  

The nurse is providing patient teaching for the client with Chronic Kidney disease. Which statement best describes the rationale of why the patient is experiencing metabolic acidosis?