Question: Noah Rivera, an elementary-aged patient, is brought in for vomiting and a decreased level of consciousness. He has deep, rapid breathing (Kussmaul respirations) and is lethargic but becomes irritable with stimulation. He appears dehydrated with dry mucous membranes and sunken eyes. History includes 2 weeks of increased thirst, increased urination, and weight loss. ABGs show pH 7.0, PaO2 90 mm Hg, PaCO2 23 mm Hg, HCO3 12 mmol/L. Labs show Na+ 126 mmol/L, K+ 5 mmol/L, Cl− 95 mmol/L. What is your assessment? 

Question: A patient who had an open reduction and internal fixation (ORIF) of a left lower leg fracture continues to report severe pain 20 minutes after IV morphine. Pulses are faintly palpable, and the foot is cool. Which action would the nurse take next? 

A nurse is assessing an older adult admitted after surgery who becomes suddenly disoriented and attempts to remove the oxygen tubing. The client was fully oriented earlier in the day. Which assessment finding most strongly supports delirium rather than a neurocognitive disorder?

Question: Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with hypovolemic shock has been effective? 

A nurse is caring for a client with moderate major neurocognitive disorder due to Alzheimer’s disease in a long-term care facility. The client becomes anxious when routines change, occasionally forgets how to complete basic tasks such as dressing, and sometimes becomes frustrated when unable to find words. The nurse is developing interventions to promote safety, reduce confusion, and support functional independence. Which nursing interventions are appropriate for this client?Select all that apply.

Question: The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action would the nurse take? 

Question: The nurse in the emergency department receives arterial blood gas results for 4 recently admitted patients with obstructive pulmonary disease. The results for which patient will require the most rapid action by the nurse? 

Question: A patient who has had open reduction and internal fixation (ORIF) of a hip fracture tells the nurse he is ready to get out of bed for the first time. Which action would the nurse take? 

Question: A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient? 

Question: The nurse completes an admission assessment on a patient with asthma. Which information indicates a need for discussion with the health care provider about a change in therapy?