A client with 35% total body surface area deep partial-thickness burns from a house fire is admitted to the burn unit. Which risk factors place this client at highest risk for fluid, electrolyte, and acid-base imbalances? (Select all that apply)

A nurse assesses an 85-year-old client with advanced dementia following hip surgery. The client cannot verbally communicate pain intensity but exhibits restlessness, facial grimacing, and resists repositioning. The family states, “She’s always confused, so this is normal behavior.” Which nursing action demonstrates appropriate clinical judgment?

A nurse cares for a 72-year-old postoperative client on a medical-surgical unit. The client requires vital signs every 4 hours, IV antibiotics at 2200 and 0600, and has been awake since 0500. At 2100, the client requests pain medication and states feeling tired. Which intervention best promotes a complete sleep cycle?

A nurse conducts a well-child clinic and assesses four clients with parent-reported sleep concerns. Which client’s sleep pattern represents the greatest deviation from expected age-related norms requiring further evaluation?

A nurse assesses a 76-year-old client who fell at home. The client has weakness in lower extremities, unsteady gait, and a previous fall history. The home has multiple throw rugs and dim hallway lighting. Which clinical judgment process demonstrates the nurse’s synthesis of critical thinking elements?

A nurse is reviewing the benefits of preoperative education with a client. Which outcomes are associated with preoperative teaching? Select all that apply.

A long-term care client initially presented with a sacral pressure injury characterized by full-thickness skin and tissue loss with exposed muscle and bone. After several months of intensive wound care, the wound bed is now significantly smaller, healthy granulation tissue is abundant, and the tunneling has resolved. How should the nurse accurately describe the current state of this client’s pressure injury in the medical record?

Explain the General Adaptation Syndrome (GAS) and the three(3) stages.

A client recovering from a stroke has difficulty perceiving objects on their left side and does not acknowledge people approaching from that direction. The nurse understands that this is an example of which sensory alteration?

A nurse evaluates a 42-year-old client on postoperative day 8 following exploratory laparotomy. The incision appears pink with visible capillary loops, and the client reports the wound feels “tight.” Laboratory results show hemoglobin 10.2 g/dL and albumin 3.0 g/dL. Which physiological process best explains the wound’s current appearance and the client’s sensation of tightness?