A nurse is assessing a patient who was involved in a motor vehicle accident and suspects a tension pneumothorax. Which of the following clinical findings would confirm this suspicion?

Which client is at the greatest risk for pressure ulcer development?

A patient with a serum sodium level of 125 mEq/L is being treated for hyponatremia. Which of the following interventions should the nurse include in the care plan?

In developing a care plan for a patient with an open reduction internal fixation (ORIF) of an open displaced fracture of the tibia,  what is the priority nursing diagnosis?

Which intervention is most effective in mobilizing secretions in a patient with pneumonia?

A client presents with a pressure ulcer on the ankle. What should the nurse do first?

A patient is admitted to the ER with severe fatigue and confusion. Lab studies are done. Which lab value will require the most immediate action by the nurse?

A patient develops megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of:

A 48-year-old patient is taking glipizide (Glucotrol) bid for control of Type 2 diabetes. Which statement by the patient indicates that he needs additional teaching about is medication?

A client is brought to the emergency department after wandering on the street. The client is confused and verbalizes double vision, headache, and shakiness. Laboratory data reveal a serum blood glucose of 52 mg/dl. Which questions, asked by the nurse, may reveal more data related to the client’s condition? (Select all that apply)