A 42-year-old client presented to the ED with nausea, vomiting, and right upper quadrant pain, and was admitted to the medical unit with a diagnosis of acute hepatitis B. Over the past 24 hours, the client has developed worsening lethargy, new-onset confusion, and easy bruising with petechiae over the lower extremities. Laboratory results show an elevated INR of 3.0 (increasing from baseline 1.1).   Based on these findings, the nurse recognizes that the client is developing [diagnosis] and needs immediate [treatment]. 

Which finding would most concern the nurse during a tertiary survey?

A client with decompensated cirrhosis and large‑volume ascites develops decreasing urine output, rising creatinine, and low urine sodium. Hepatorenal syndrome is suspected. Which nursing action best supports the intended treatment plan for this condition? 

A nurse is assessing four clients in an outpatient clinic. Which client’s presentation is most consistent with acute glomerulonephritis (AGN)?   

A nurse is caring for a client who was rescued from a structure fire and sustained extensive burn injuries to the chest and upper extremities. The client is in the emergency department and is demonstrating tachycardia, hypotension, and increasing hematocrit levels. Airway patency is intact at this time.  Which intervention is the priority for this client?   

A client with an acute kidney injury (AKI) has the following:  Potassium: 6.7 mEq/L (normal range 3.5-5.0 mEq/L) ECG: Peaked T waves  Urine output: 10 mL/hr  What is the priority nursing intervention? 

A patient involved in a high‑speed motor vehicle collision (MVC) initially stabilizes after resuscitation. Which finding during ongoing care would be most concerning for missed injury? 

62-year-old client had a chest tube placed three days ago for a left-sided hemothorax, connected to a water-seal drainage system. At shift report, the system was functioning properly, the dressing was clean, dry, and intact, and drainage had been decreasing. The last output was recorded at 0600. At 0800, assessment findings include blood pressure 102/64 mmHg (baseline 128/80 mmHg), heart rate 110 bpm, and 360 mL of serosanguinous drainage in the past 2 hours. What is the priority nursing action?  

A 52-year-old client is brought to the emergency department after a motor vehicle collision with a deep laceration to the left thigh. The client appears pale, diaphoretic, and anxious, stating “I feel very lightheaded.” The pressure dressing over the wound is saturated with bright red blood. Initial vital signs are:  BP: 82/54 mmHg   HR: 126 bpm   RR: 24/min, shallow   Which intervention should the nurse prioritize? 

A client is receiving spinal anesthesia for a surgical procedure. The nurse recognizes that the development of [symptom] may indicate a complication of spinal anesthesia due to [cause]