A client is admitted to the emergency department after being found unconscious at home following a fall down a flight of stairs. The client is suspected of having a stroke. During the nurse’s assessment, the following findings are noted:Eye Opening: Opens eyes only in response to verbal commandVerbal Response: Utters inappropriate wordsMotor Response: Withdraws from painful stimulusUsing the Glasgow Coma Scale (GCS), what is the client’s total score?Glasgow Coma ScaleParameterFinding Score Eye-openingSpontaneously4Opens to verbal command3Opens to pain2Do not open1Best verbal responseOriented5Confused conversation4Inappropriate words3Incomprehensible sounds2No verbalization1Best motor responseObey command6Localizes pain4Withdraws from pain4Flexion to pain (decorticate)3Extension to pain (decerebrate)2No motor responses1 

A client with diabetic ketoacidosis (DKA) was admitted to the intensive care unit 4 hours ago and has two IV lines infusing normal saline solution. The client’s blood glucose level has now decreased to 250 mg/dL. Which intervention should the nurse implement next?

A nurse is caring for a client with acute kidney injury (AKI) who develops hyperkalemia. The client’s ECG shows peaked T waves and widened QRS complexes. Which of the following actions should the nurse take first?

A school nurse suspects a 6-year-old child is being physically abused based on multiple injuries inconsistent with the parent’s explanation. What is the nurse’s legal obligation?

A client with a severe traumatic brain injury (TBI) is transferred to the ICU. A ventriculostomy catheter has been inserted into the right lateral ventricle to continuously monitor intracranial pressure (ICP) and allow for drainage of cerebrospinal fluid (CSF) as needed.Normal ICP = 5–15 mm Hg. Upon admission to the ICU, the nurse notes that the ventriculostomy drainage system is open to drainage and the ICP monitor reads 25 mm Hg. Which action should the nurse take first?

A nurse working in a busy emergency department receives two critically ill clients at the same time. One client is a well-known member of the community, while the other is a homeless individual. How should the nurse prioritize care in this situation?

A nurse is caring for a client with pre-renal acute kidney injury (AKI) following major abdominal surgery. The nurse notes the following assessment findings: The client’s urine output over the past 2 hours is 50 mL, blood pressure is 90/58 mmHg, and heart rate is 114 beats per minute with sinus tachycardia. Which provider order should the nurse initiate first?

A newly admitted client to the intensive care unit after a motor vehicle accident. On the second day of the hospital admission, the client developed an acute kidney injury. The nurse assessment findings are crackles in both lung bases, urine output 10 mL/hour, potassium 7.8 meq/dL, mean arterial pressure (MAP): 58 mm Hg, and renal replacement therapy is needed. Which renal replacement therapy should the nurse anticipate the provider to prescribe? 

A client is brought to the emergency department after falling down a flight of stairs. Assessment reveals:GCS score: 8 (Eye Opening 3, Verbal Response 3, Motor Response 2)Vital signs: BP 145/90 mm Hg, HR 102 bpm, RR 18/min, SpO₂ 94% on room airThe client is somnolent and responding only to verbal and painful stimuli.Given the client’s GCS of 8, what is the priority nursing intervention?

A nurse is caring for a client who has sustained a spinal cord injury at the C5 level. Which of the following assessments should the nurse prioritize?