An emergency room nurse is assessing a 60-year-old client who looks disheveled and angry.  As the nurse starts to get her vitals the client accuses the nurse of “hurrying” and “not attending to her needs”.  What should the nurse do next?

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)?

A home care nurse should teach the client that for the first week after eye surgery for cataract removal: Select all that apply.

A 60-year-old client has a hematocrit of 55% and a history of polycythemia vera. The nurse is explaining which cardiovascular complication is associated with this diagnosis? 

The multi-organ dysfunction syndrome (MODS), client complains of pain in the distal digits and in the abdomen.  You notice she has multiple petechiae on her skin and that her urine is positive for occult blood.  Select the possible phenomena that might be occurring from the list below:

The nurse is caring for a client in the intensive care unit.  The client is admitted with a traumatic brain injury and has an increased intracranial pressure.  The provider calls the unit and tells the unit secretary to prepare for a lumbar puncture for this patient. The best action by the nurse is to  

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:

The nurse is caring for a 52 year old male with Parkinson’s disease which is progressing rapidly. The client has made it clear that his preference is to receive hospice care at home. What interventions should the nurse prioritize in the plan of care? 

The nurse is caring for four patients in a long-term acute care facility. Which of the following clients indicate a readiness to wean from mechanical ventilation?

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: