The nurse is caring for a client who presents with severe right-sided flank pain, nausea, and vomiting. The client denies any past medical history. Vital signs: Temperature 98.2° Fahrenheit, Blood pressure 92/52 mmHg, Pulse: 118 beats/min, Respirations: 22 breaths/min, O2 Saturation: 95%. The priority nursing action is to:

A client is on a ventilator in the intensive care unit (ICU).  Which of the following measures should the nurse implement to prevent ventilator acquired pneumonia (VAP)?

The client presents in the emergency room with left sided weakness and left facial droop, one blood pressure reading is 240/130.   The priority nursing action for this client is:

A nurse would take which of the following actions as part of routine care for a client who just underwent angiography using the right femoral artery as the insertion site for the catheter?

A nurse is caring for a client in a coma secondary to brainstem injury.  Nursing interventions in the acute phase are directed toward the goal of:

A nurse is caring for a client in the surgical intensive care unit preparing for intracranial surgery. During the admission the client gives short quick answers and asks the nurse, “Will this take much longer? I would really like to get some rest before the procedure.” What is the most appropriate action by the nurse? 

The client’s new demand pacemaker rate is set at 54.  The nurse notes the client’s pulse is 56.  What nursing action is indicated?

The nurse is caring for a client diagnosed with a cerebral vascular accident. The client has receptive aphasia. The client will have difficulty with 

The nurse is caring for a client ordered warfarin 7.5 mg orally daily. The nurse understands it is imperative to monitor daily labs. What is the priority lab for this patient? 

The homecare nurse is teaching the client how to self-administer eye drops to treat glaucoma.  Which of the following actions should the client perform first?