During an ongoing mass casualty event, the nurse is conducting re-triage 45 minutes after initial assessment. A victim originally tagged as yellow (delayed) is now confused, has a respiratory rate of 34 breaths per minute, and has a weak and thready radial pulse. Which action reflects correct re-triage practice?

The nurse receives morning handoff for four patients. Which patient should the nurse assess first?

A patient with bipolar disorder is being discharged on lithium carbonate 300 mg three times daily. Which statement by the nurse is most important for safe medication management at home?

A patient is receiving vancomycin 1.5 g IV every 12 hours for MRSA bacteremia. The nurse draws a trough level 30 minutes before the scheduled dose and the result is 22 mcg/mL. The target trough range for serious infections is 10 to 20 mcg/mL. Which action should the nurse take?

A client with septic shock has received 30 mL/kg of IV crystalloid over 3 hours. The current MAP is 62 mmHg and lactate is 4.2 mmol/L. The provider orders an additional 500 mL fluid bolus. Which assessment finding would lead the nurse to question this order?

A client in septic shock has been on norepinephrine for 18 hours. Despite appropriate antibiotic therapy and adequate fluid resuscitation, vasopressor requirements continue to increase. Which intervention should the nurse prepare to administer?

A nurse completes a home safety visit for a 72-year-old man with Parkinson’s disease who has a festinating gait, meaning he walks with rapid, involuntary short shuffling steps and has difficulty stopping or changing direction. His wife manages all of his medications. The nurse notes three concerns: a telephone cord lying loose across the main hallway he walks through many times each day, a 1.5-inch raised threshold at the bathroom doorway, and warfarin stored in an unlabeled weekly pill organizer. Which hazard should the nurse address FIRST?

A nurse caring for a mechanically ventilated client in acute respiratory failure notes that the high-pressure ventilator alarm is sounding. Assessment reveals the client is biting on the endotracheal tube and the airway pressure reading is elevated. Which action should the nurse take FIRST?

A nurse is 15 minutes into transfusing packed red blood cells when the client reports low back pain and burning at the IV site. The nurse notes the temperature has increased from 37.0 to 38.7 degrees Celsius and blood pressure dropped from 128/76 to 96/60 mmHg. Which sequence of actions does the nurse perform?

A patient who underwent coronary artery bypass grafting 16 hours ago develops a sudden irregularly irregular ventricular rate of 122 beats per minute on continuous telemetry. The nurse notes an absence of identifiable P waves and a chaotic fibrillatory baseline between QRS complexes. Which complication does the nurse recognize?

A patient receiving total parenteral nutrition (TPN) via a right subclavian central venous catheter suddenly reports shortness of breath and chest pain. The nurse assesses absent breath sounds over the right lung. Which action should the nurse take first?

A nurse is assessing a male patient who has had an indwelling urinary catheter for six days following total hip replacement surgery. The patient reports burning around the catheter, and the nurse observes cloudy urine with a strong odor. Which action should the nurse take first?

A nurse is performing a developmental screening for a 5-year-old. Which finding warrants referral for further evaluation?

A patient calls the clinic to report that she had unprotected intercourse approximately 62 hours ago and is asking about emergency contraception options. Which information should the nurse provide?

An inpatient psychiatric unit admits three clients simultaneously following a local disaster. The normal structured routine is disrupted, and the unit nurse observes two minor physical altercations among clients within 24 hours. Which action should the nurse prioritize to restore the therapeutic milieu?

A client with obsessive-compulsive disorder reports spending 3 to 4 hours daily washing hands until they bleed and checking whether the stove is off. The client states, ‘I know this is irrational, but I absolutely cannot stop.’ The nurse explains that compulsions in OCD primarily serve to: