The nurse is caring for the following patients. Which of the following should the nurse assess first?

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 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:

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?

A client is diagnosed with Acute Kidney Injury related to an intra-renal cause. The nurse identifies which is the most likely cause of the AKI? 

The nurse is providing information at a health fair about the risk factors for chronic kidney disease.  Which of the following conditions does the nurse include in the education session? Select all that apply

A nurse is working as a triage nurse in the emergency department. Place the following patients in the order in which they should receive care.  1.    Infant with temperature of 103.2 actively having a seizure.2.    Male patient with acute pancreatitis who smells of alcohol.3.    Female with acute chest pain and reports of shortness of breath. 4.    Adolescent with a blood glucose level of 110 mg/dl.5.    Child with a non-life-threatening cut that needs stitches.

The nurse is suctioning a client through a tracheostomy tube.  During this procedure the nurse notes cardiac irregularities on the monitor.  Which of the following is the most appropriate intervention?

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)?