The nurse is caring for a client admitted to the ED following a fall from a 10-foot ladder. Upon admission, the nurse assesses the client to be awake, alert, and moving all four extremities. The nurse also notes bruising behind the left ear and straw-colored drainage from the left nare. Which of the following is the most appropriate nursing action?

The nurse is caring for a client admitted to the ED following a fall from a 10-foot ladder. Upon admission, the nurse assesses the client to be awake, alert, and moving all four extremities. The nurse also notes bruising behind the left ear and straw-colored drainage from the left nare. Which of the following is the most appropriate nursing action?

The nurse has obtained the following Arterial Blood Gas (ABG) reading from the client: pH 7.30, CO2 63, HCO3 26, PaO2 92% The nurse would anticipate that this reading is a result of which of the following conditions?  

The picture below represents the the femur fracture that was sustained by the client following a motor vehicle accident: The client’s vital signs are: B/P 98/50 mmHg, Pulse 130 BPM, RR 24, Temp 37.5C, Pain 10 (0-10 scale). The nurse know that the client is at risk for which of the following? Select all that apply.

A client is admitted with a large right tension pneumothorax after a ski pole fell on them and created a sucking chest wound. Which of the following findings would best confirm the presence of a tension pneumothorax?

CASE STUDY QUESTION The following questions pertain to the client who is newly admitted in the ICU with diabetic ketoacidosis.   QUESTION: The nurse knows that the presence of ketones in the blood in this client is the result of which of the following?

The nurse is caring for a client with a gastrostomy tube who is getting continuous enteral feedings via a feeding pump at 75 mL/hour. The client complains of nausea and abdominal pain. The nurse checks gastric residual and obtains 250 mL. Which of the following interventions should the nurse do next?

CASE STUDY QUESTION The following questions pertain to the client who is newly admitted in the ICU with diabetic ketoacidosis.   QUESTION: The nurse knows that the presence of ketones in the blood in this client is the result of which of the following?

Which of the following disorders cause metabolic acidosis? Select all that apply.

The nurse is caring for a client having an episode of status epilepticus. Vital signs assessed by the nurse include blood pressure 160/100 mmHg, heart rate 145 beats/min, respiratory rate 36 breaths/min, SpO2 96% on 100% supplemental oxygen by non-rebreather mask. After establishing an IV line, which order by the healthcare provider should the nurse implement first?