A patient with a bioprosthetic mitral valve presents with fever, a new regurgitant murmur, and splinter hemorrhages. Two sets of blood cultures are positive for viridans group streptococci. Which complication should the nurse anticipate as most immediately life-threatening?

A patient undergoes cardiac catheterization with coronary angiography and receives 160 mL of iodinated contrast. The patient has a baseline creatinine of 1.4 mg/dL and type 2 diabetes. Which nursing intervention is MOST important to minimize the risk of contrast-associated kidney injury?

A patient who had a femoral central venous catheter placed five days ago in the emergency department now has fever, chills, and erythema at the insertion site. Blood cultures are drawn. Which next step is most aligned with central line infection management and prevention guidelines?

A patient with type 2 diabetes presents with a 4-day history of an infected foot wound. The area around the wound is erythematous, warm, and swollen extending 3 cm beyond the wound edge. The patient has crepitus on palpation of the surrounding tissue. Which action should the nurse anticipate as the most urgent priority?

A patient who underwent thoracic duct ligation during esophageal cancer surgery develops progressive dyspnea. Chest X-ray shows a large left pleural effusion. Thoracentesis yields milky fluid with a triglyceride level of 320 mg/dL. Which dietary modification is most appropriate as part of initial conservative management?

A 38-year-old woman who is 14 weeks pregnant is admitted for confirmed pulmonary embolism. She is hemodynamically stable with an SpO2 of 94% on 2 L nasal cannula. Which anticoagulation strategy is most appropriate?

A nurse caring for a ventilator-dependent patient notices that a resident physician is about to perform a procedure the patient’s advance directive explicitly prohibits. The nurse has already verbally informed the resident, who dismisses the concern. What is the nurse’s next best action?

A patient recovering from coronary artery bypass surgery has limited English proficiency, lives alone, has no transportation, and was recently laid off from work. When the care team plans discharge using a synergy-based assessment of patient needs, which patient characteristic is most directly reflected by these social and environmental factors?

A case manager identifies that a patient with pneumonia who is clinically stable for discharge has remained in the progressive care unit for two additional days because of delays in arranging home oxygen equipment. Which systems-level strategy most directly addresses this type of resource utilization problem?

A progressive care unit is using a Plan-Do-Study-Act (PDSA) cycle to test a new early mobility protocol. After the ‘Do’ phase, the nurse champion reviews the data and finds that only 3 of the 12 eligible patients received the protocol. Which action aligns with the ‘Study’ phase of PDSA?

A 54-year-old patient with short bowel syndrome following massive small bowel resection, with about 80 cm of small bowel remaining, has been on home parenteral nutrition for 6 months. Labs reveal calcium 7.8 mg/dL, magnesium 1.2 mEq/L, and a 24-hour urine oxalate of 68 mg per day, with normal being less than 40 mg per day. The patient reports intermittent flank pain and passage of small stones. Which mechanism best explains the hyperoxaluria and stone formation?

A patient who underwent Roux-en-Y gastric bypass 2 years ago is admitted with a serum calcium of 7.6 mg/dL, vitamin D level of 14 ng/mL, and bone pain. Parathyroid hormone is elevated. Which mechanism best explains this patient’s metabolic bone disease?

A 52-year-old immunocompetent man is transferred to the progressive care unit after three days of fever, headache, and progressive confusion. CSF shows 320 white cells (85 percent lymphocytes), protein 95 mg/dL, and glucose 58 mg/dL with a serum glucose of 102 mg/dL, and the Gram stain is negative. MRI shows T2 hyperintensity in the bilateral medial temporal lobes. Which empiric action is most appropriate?

A nurse repositions a patient with an external ventricular drain to perform oral care. Immediately after repositioning, the nurse observes a large, rapid outflow of CSF into the drainage chamber. Which action should the nurse take first?

A patient on a continuous IV insulin infusion has had blood glucose values of 182, 170, 165, and 162 mg/dL over the past four hours. The ordered target range is 140 to 180 mg/dL. Based on this trend, which adjustment is MOST appropriate?

A patient with known central diabetes insipidus is receiving intranasal desmopressin (DDAVP). The nurse notes the patient’s urine output has dropped to 20 mL/hour and serum sodium is now 128 mEq/L. What is the most likely explanation?

A 67-year-old patient with CKD stage 4 (eGFR 22 mL/min/1.73 m2) and compensated metabolic acidosis (bicarbonate 16 mEq/L) is admitted to the progressive care unit. Which long-term consequence of untreated metabolic acidosis in CKD should the nurse understand when educating the patient?

A nurse is caring for a patient with CKD stage 4 and heart failure who is receiving a continuous furosemide infusion. The serum potassium is 3.0 mEq/L and serum magnesium is 1.4 mEq/L. Despite potassium replacement, the potassium remains low. Which electrolyte relationship explains this finding?

A 45-year-old man with schizophrenia and a history of assaultive behavior is admitted for pneumonia. He becomes acutely psychotic, shouting incoherently and raising a meal tray in a threatening manner. The charge nurse activates the behavioral emergency response team. While waiting for the team, which action by the bedside nurse poses the greatest safety risk?

A 48-year-old woman with newly diagnosed stage IV cancer is admitted for pain management. She repeatedly asks why this happened to her when she did everything right, while her husband sits silently at the bedside. Which nursing approach best supports both the patient and her family during this hospitalization?

A 70-year-old man with a history of heart failure (EF 35 percent) receives 2 units of packed red blood cells over 3 hours for a hemoglobin of 6.9 g/dL. One hour after the transfusion is complete he develops worsening dyspnea, his oxygen saturation drops to 88 percent, blood pressure rises to 178/96 mmHg, and bilateral crackles are noted. Chest X-ray shows new pulmonary edema with a widened vascular pedicle. Which transfusion complication is most consistent with these findings, and what is the priority intervention?

A nurse caring for a neutropenic patient (ANC 180/mcL) is preparing the room and care plan. Which dietary guideline is most appropriate for this patient?

A 65-year-old man underwent intramedullary nail fixation of a femoral shaft fracture 48 hours ago. He develops acute onset confusion, petechiae across his upper chest and axillae, and oxygen saturation of 88% on room air. His temperature is 38.6 degrees C. Which condition is the highest priority concern?

A 78-year-old woman is on postoperative day 1 following left hip hemiarthroplasty performed through a posterior approach for a femoral neck fracture. The physical therapist has cleared her for weight-bearing as tolerated. During ambulation with a walker, the patient pivots her left foot inward to retrieve a dropped item. Which complication is the nurse most concerned about?