17. The nurse is caring for a client who is receiving isotonic intravenous (IV) fluids at an infusion rate of 125 mL/h. The nurse performs an assessment and notes a heart rate of 102 beats per minute, a blood pressure of 160/85 mm Hg, and crackles auscultated in both lungs. Which is the priority action for the nurse?

28. A patient is admitted to the unit with chronic gastrointestinal symptoms.  The nurse is reviewing the laboratory values and notes which of the following indicates the patient may be experiencing hypoxemia? 

15. A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse recognize as an early complication of this therapy?

19. The nurse is assessing a client brought to the emergency department for treatment for dehydration. The nurse assesses a respiratory rate of 26 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 86/50 mm Hg, and a temperature of 39.5° C. The client becomes dizzy when transferred from the wheelchair to a bed. The nurse notes cool, clammy skin. The patient’s symptoms correlate with which of the following? 

31. When palpating a child’s cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm.  Which of the following best describes the reason for this finding? 

38. A 60-year-old patient with congestive heart failure (CHF) and a history of hypertension is admitted to the hospital with acute pulmonary edema. The healthcare provider orders an IV infusion of a hypertonic solution to manage electrolyte imbalances. The nurse is preparing to administer the infusion. What complication should the nurse be most concerned about for this patient, given their hypervolemic state?

27. Which of the following postural abnormalities is characterized by increased lumbar curvature and is often referred to as “swayback?”

14. Which of the following sites should the nurse select to administer an intramuscular injection to a six month old infant? 

5. A nurse is caring for a client who acquired hepatitis A from consuming contaminated food. The client’s mouth is an example of which of the following links in the chain of infection?

46. The nurse conducting a routine health assessment on a 45-year-old female patient. The patient reports a history of having difficulty seeing at night. As part of the assessment, the nurse will examine her eyes for any abnormalities, including testing the pupils and assessing visual function. Which of the following steps would the nurse perform to assess the patient’s pupillary accommodation during the eye exam?