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Author Archives: Anonymous

A nurse is assisting the health care provider who is intubat…

A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority?

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The nurse has identified a nursing diagnosis of acute pain r…

The nurse has identified a nursing diagnosis of acute pain related to inflammatory process for a patient with acute pericarditis. An appropriate intervention by the nurse for this problem is to

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A client is on a ventilator and is sedated. What care may th…

A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)?

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A client is in the hospital after suffering a myocardial inf…

A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the client’s O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best?

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A nurse assesses a client after administering isosorbide mon…

A nurse assesses a client after administering isosorbide mononitrate (Imdur). The client reports a headache. Which action should the nurse take?

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A nurse answers a call light and finds a client anxious, sho…

A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority?

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A nurse cares for a client with right-sided heart failure. T…

A nurse cares for a client with right-sided heart failure. The client asks, “Why do I need to weigh myself every day?” How should the nurse respond?

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A nurse assesses clients on a cardiac unit. Which client sho…

A nurse assesses clients on a cardiac unit. Which client should the nurse identify as being at greatest risk for the development of left-sided heart failure?

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An intubated client’s oxygen saturation has dropped to 88%….

An intubated client’s oxygen saturation has dropped to 88%. What action by the nurse takes priority?

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While assessing a client on a cardiac unit, a nurse identifi…

While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. Which action should the nurse take next?

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