A nurse receives shift report on four patients. Which patient requires the most urgent initial assessment?

A) A 68-year-old with type 2 diabetes who has a blood glucose of 214 mg/dL and denies symptoms
B) A 54-year-old on post-operative day two after hip replacement who rates pain at 6 out of 10
C) A 72-year-old with chronic heart failure whose total urine output over the past four hours is 18 mL
D) A 45-year-old recovering from community-acquired pneumonia with a temperature of 37.9 degrees C

A nurse applies Maslow’s hierarchy of needs to prioritize clients during a busy shift. One client awaits discharge teaching. A second client requests a sleeping aid. A third client cannot open meal containers and has not eaten. Which client should the nurse address first?

A client is admitted with a urinary tract infection. Urine culture confirms Escherichia coli sensitive to trimethoprim/sulfamethoxazole. The client’s allergy record documents a prior reaction to a sulfonamide antibiotic described as Stevens-Johnson syndrome. The nurse anticipates that the prescriber will:

A nurse is to infuse 1,000 mL of 0.9% sodium chloride over 8 hours using a gravity drip set with a drop factor of 15 gtts/mL. What drip rate should the nurse set?

A home health nurse visits a client with COPD who reports persistent headaches and fatigue over the past week. The client uses a gas stove daily and the nurse observes no carbon monoxide detector in the home. What should the nurse do first?

A nurse notices a freshly mopped, wet floor near the nurses’ station. A client with a history of unsteady gait is walking directly toward the area. Which action should the nurse take first?

A nurse caring for a 77-year-old client with a longstanding dementia diagnosis notes that the client has become increasingly combative and incoherent over the past 18 hours, which is a marked change from a stable cognitive baseline. The nurse suspects superimposed delirium. Which assessment finding would best support this suspicion?

A client recently diagnosed with terminal cancer tells the nurse, ‘Why is God punishing me? I have always tried to live a good life.’ Which nursing response is most therapeutic?

A PN monitors a client admitted after traumatic head injury. Over 90 minutes the blood pressure rises from 118/76 mmHg to 174/48 mmHg, the heart rate decreases from 82 to 50 beats per minute, and respirations become slow and irregular. The client now responds only to painful stimuli. Which action is the priority?

A 9-year-old patient is in the post-anesthesia care unit 4 hours after a tonsillectomy. The nurse observes the child repeatedly swallowing every 30 to 60 seconds and notes the heart rate has increased from 88 to 114 bpm. Which complication does this assessment most strongly suggest?

A nurse is preparing to administer a bolus tube feeding through a gastrostomy tube. Before beginning, the nurse aspirates 275 mL of gastric residual. The client has no nausea, vomiting, or abdominal distension, and bowel sounds are present in all quadrants. The facility protocol specifies holding tube feedings when residual volume exceeds 250 mL. Which action should the nurse take?

A nurse prepares to administer a bolus gastrostomy tube feeding and aspirates 520 mL of gastric residual volume. Which action is most appropriate?

A client with rheumatoid arthritis takes weekly methotrexate and a daily NSAID. The client presents to the clinic reporting fatigue, painful oral ulcers, and easy bruising over the past two weeks. Which laboratory finding is most critical to report to the provider?

A client who has had continuous nasogastric suction for 48 hours develops muscle cramps and tingling in the fingers. ABG values are pH 7.50, PaCO2 47 mmHg, HCO3 32 mEq/L. What is the primary cause of this acid-base imbalance?

A client at 36 weeks gestation calls the clinic reporting decreased fetal movement over the past 24 hours. The nurse instructs the client on fetal movement counting. Which instruction is most consistent with evidence-based practice?

A nurse is educating a patient at 30 weeks gestation who received a Tdap vaccine 4 years ago. The provider has ordered another Tdap dose today. The patient asks why she needs a repeat vaccination so soon. Which explanation is most accurate?