A nurse is assessing a patient suspected of experiencing anaphylactic shock. Which of the following symptoms is the most concerning and requires immediate intervention?

A nurse is assessing a patient at risk for pressure ulcers. Which finding is most consistent with a Stage 1 pressure ulcer? 

The nurse is teaching the patient about open-heart surgery. Which of the following items is NOT part of the teaching plan?

A nurse is providing care for a patient with hyperthyroidism and exophthalmos. Which intervention is most appropriate to promote comfort for this patient? 

A patient is hospitalized with a possible diagnosis of Cushing’s syndrome. Which laboratory result would the nurse anticipate if the diagnosis is confirmed? 

A nurse is assessing a patient with suspected Acute Respiratory Distress Syndrome (ARDS). Which clinical finding is most indicative of ARDS? 

A client converts from normal sinus rhythm at 80 bpm to atrial fibrillation with a ventricular response at 144 bpm. Blood pressure is 162/74 mm Hg. Respiratory rate is 20 breaths per minute with normal chest expansion and clear lungs bilaterally. IV heparin and Diltiazem (Cardizem) are administered. The nurse caring for the client understands that the main goals of treatment include all of the following except:

A postoperative client is admitted to the intensive care unit (ICU) with hypovolemic shock. Which nursing action will the nurse delegate to certified nursing assistant? 

The nurse is caring for a 70-year-old client who had a cardiac catheterization yesterday to confirm an MI and has completed discharge teaching using the teach-back method. This morning the nurse is evaluating the client’s understanding of the discharge plan of care. For each of the statements made by the client, specify whether the statement indicates an Understanding or Requires Further Education of the teaching provided. “I will take only my aspirin and not the clopidogrel.”: [statement1] “I will be sure to carry my nitroglycerin with me.”: [statement2] “I will exercise indoors only.”: [statement3]

An emergency department triage nurse is evaluating a patient reporting general malaise. The assessment reveals jaundice and increased abdominal girth. Which question would best help determine the cause of the patient’s symptoms?