A nurse in an intensive care unit is caring for a client who had an acute myocardial infarction (MI) and had cardiac biomarkers drawn. The nurse knows that the results of the cardiac biomarkers studies help determine which of the following?

                 A patient who suffered a cerebrovascular accident experiences right-sided arm and leg paralysis and facial drooping on the right side. When admitting the patient, which additional clinical manifestation will the nurse expect to find?

A patient undergoing external radiation has developed a dry desquamation of the skin in the treatment area. The nurse teaches the patient about management of the skin reaction. Which statement, if made by the patient, indicates the teaching was effective?

A nurse is caring for a client who has undergone a radical prostatectomy to treat prostate cancer and has an indwelling foley catheter in place. For several hours, the client’s urinary output is adequate. After 5 hr, the nurse notes that the catheter has drained no urine during the prior hour. Which action will the nurse do first?

The nurse is preparing to initiate Bucks traction on an 87 yo client with a fractured left hip.  Which data should the nurse report to the health-care provider immediately?

A nurse on a medical-surgical floor received report on the following clients.  Which client should be seen first?  

Which intraoperative activity is specific to the role of the scrub nurse?

The nurse on a medical-surgical unit is caring for a 70 year old male with Paget’s Disease. Which information is most important to include in the plan of care?

A nurse is caring for a 59 year male old patient with a waddling gait and severe pain. In addition to bone scan and x-rays, the nurse anticipates which laboratory test will be sent to confirm a diagnosis of Paget’s disease?

The nurse supervises the care of a patient with a temporary radioactive cervical implant (brachytherapy). Which action by unlicensed assistive personnel (UAP), if observed by the nurse, would require an intervention?