Mr. Lewis, a 69-year-old male arrives to the emergency department with his wife, who reports he suddenly became confused, had slurred speech, and appeared weak while sitting at the table approximately 30 minutes ago. History: • Type 2 Diabetes • Hypothyroidism • Hypertension • Hyperlipidemia • Coronary artery disease Initial Assessment Findings: • Slurred speech • Right-sided weakness • Confusion • Diaphoretic • Tremors • Pale appearance • Eyes open to voice • Inappropriate words • Withdraws from pain Admission Vital Signs: • Blood pressure: 185/90 • Heart rate: 108 • Respiratory rate: 22 • Temperature: 98.1 • Oxygen saturation: 96% on room air Laboratory Results: • Hemoglobin: 9.1 g/dL (12-16 g/dL) • Glucose: 48 mg/dL Which modifiable risk factors increase Mr. Lewis’ risk for stroke? Select all that apply.

Mr. Lewis, a 69-year-old male arrives to the emergency department with his wife, who reports he suddenly became confused, had slurred speech, and appeared weak while sitting at the table approximately 30 minutes ago. History: • Type 2 Diabetes • Hypothyroidism • Hypertension • Hyperlipidemia • Coronary artery disease Initial Assessment Findings: • Slurred speech • Right-sided weakness • Confusion • Diaphoretic • Tremors • Pale appearance • Eyes open to voice • Inappropriate words • Withdraws from pain Admission Vital Signs: • Blood pressure: 185/90 • Heart rate: 108 • Respiratory rate: 22 • Temperature: 98.1 • Oxygen saturation: 96% on room air Laboratory Results: • Hemoglobin: 9.1 g/dL (12-16 g/dL) • Glucose: 48 mg/dL After receiving IV dextrose, the patient becomes more alert. Updated history reveals a diagnosis of Vitamin B12 deficiency anemia. Which assessment finding should the nurse prioritize next?

Mr. Lewis, a 69-year-old male arrives to the emergency department with his wife, who reports he suddenly became confused, had slurred speech, and appeared weak while sitting at the table approximately 30 minutes ago. History: • Type 2 Diabetes • Hypothyroidism • Hypertension • Hyperlipidemia • Coronary artery disease Initial Assessment Findings: • Slurred speech • Right-sided weakness • Confusion • Diaphoretic • Tremors • Pale appearance • Eyes open to voice • Inappropriate words • Withdraws from pain Admission Vital Signs: • Blood pressure: 185/90 • Heart rate: 108 • Respiratory rate: 22 • Temperature: 98.1 • Oxygen saturation: 96% on room air Laboratory Results: • Hemoglobin: 9.1 g/dL (12-16 g/dL) • Glucose: 48 mg/dL Which finding requires the most immediate nursing action?

A patient with hyperthyroidism has a heart rate of 148 bpm and tremors. Which intervention is the priority?

A nurse is reviewing patients with suspected stroke. Which patient should not receive thrombolytic therapy?

Which statement by a patient with neutropenia indicates correct understanding of infection prevention?

A nurse is caring for a patient following a stroke who has difficulty swallowing. Which intervention is most appropriate to reduce aspiration risk?

A patient with symptomatic anemia is ordered to receive 300 mL of packed red blood cells over 4 hours. The blood administration tubing has a drop factor of 20 gtt/mL. How many gtt/min should the nurse set the infusion to deliver? (round to the whole number)

Which finding indicates a patient with anemia is experiencing a serious complication?

A patient following pituitary surgery has urine output of 850 mL/hr with very dilute urine. Which intervention is the priority?