S: 58 year old male client was in a Motor Vehicle Collision three days ago, he was found to have hit another vehicle head on after experiencing a myocardial infarction while driving. The client was trapped inside the vehicle and had to be extricated by EMS personnel. Client was found to have blunt force trauma to the head and chest. On CT scan performed on arrival to the emergency department he was found to have a brain bleed and bleeding from the liver and spleen. He decided yesterday to sign a DNR order and physician is aware. Client is of Jehovah’s Witness religion which he practices regularly. He was stabilized in the emergency department and is planned to have surgery on the abdominal cavity tomorrow, due to the DNR order this surgery was cancelled. He was admitted to the palliative care unit for further care at this time. B: Client’s past medical history: Hypertension, Hyperlipidemia, past smoker for 25 years smoking 3 packs per day, mild obesity with a sedentary lifestyle. A: BP: 80/40, HR 140, RR 24, SPO2 94% on 2L via NC, T 95.0 F. Client is alert and oriented X 4 but lethargic, the previous shift noted some periods of confusion. He appears to be anxious and very pale and is having Cheyne-stokes respirations with significant periods of apnea. Client’s abdomen is firm and distended. Lung sounds are diminished in the bases and crackles can be heard in the upper lobes. His lower extremities are mottled in color, and cool to touch. 2+ femoral pulses with posterior tibial pulses and pedal pulses absent. 20G IV in the left anticubital heplocked. R: What is the priority action for the nurse to initiate?

A nurse is observing an assistive personnel performing postmortem care for a client who is Muslim and of the opposite gender. Which of the following actions should prompt the nurse to intervene?

Which nursing interventions would the nurse implement for the cardiovascular changes related to aging? Select all that apply.

What information would the nurse provide to the client to promote safety and assist the elderly client with fall prevention?

While performing the morning assessment the nurse identifies that the elderly client is confused. Which items are most likely the possible causes of confusion?  Select all that apply.

The nurse is caring for a client who has moderate stage of Dementia. What are the expected findings or symptoms for a client in this stage of the disease process?  Select all that apply. 

A nurse who is male approaches a female client and her husband to assess the client’s blood pressure. The husband moves his wife’s top sheet up under her chin and raises a hand like a stop sign. What should the nurse do?

The new graduate has started her first nursing job and is weighing the pros and cons of obtaining professional liability insurance. What are reasons the nurse would choose to have her own liability insurance? Select all that apply.

An adult client is receiving oxygen by simple face mask in their residence. Which statement by the client indicates that client teaching regarding the use of oxygen therapy has been effective? 

The nurse is caring for an asthma client that has been ordered an albuterol metered dose inhaler, (MDI) and a beclomethasone metered dose inhaler, MDI. Which instructions provide the best teaching regarding the proper use of these two metered dose inhalers, (MDI’s) utilizing a spacer to administer the medications? Select all that apply.