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A client with multiple sclerosis (MS) fell while walking to the bathroom. Upon transfer to the intensive care unit, the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?

A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?

Which information should the nurse include when giving discharge instructions to a client following a left eye cataract extraction with a lens implant?

A nurse is caring for a 51-year-old male client with pneumonia in the hospital. The client has a history of hypertension and takes enalapril and a multivitamin daily. His surgical history includes adenoid removal at age 4 and surgical repair of a fractured tibia at age 20.

History and Physical

The client is a 51-year-old male with pneumonia. He has a history of hypertension and takes enalapril and a multivitamin daily. His surgical history includes adenoid removal at age 4 and surgical repair of a fractured tibia at age 20.

Nurses’ Notes

The client is alert and oriented but appears fatigued. He reports shortness of breath and a productive cough with greenish sputum. The client has been receiving oxygen therapy via nasal cannula at 2 L/min. He has been compliant with his medication regimen and reports no recent changes in his health status. The client denies any chest pain but mentions occasional wheezing.

Diagnostic Results

Chest X-ray: Consolidation noted in the right middle and lower lobe consistent with pneumonia.

Vital Signs

• Temperature: 38.5°C (101.3°F)
• Heart Rate: 98 bpm
• Respiratory Rate: 24 breaths per minute
• Blood Pressure: 145/90 mmHg
• Oxygen Saturation: 92% on 2 L/min of oxygen via nasal cannula

Physical Examination Results

The client appears fatigued and is using accessory muscles to breathe. Lung auscultation reveals crackles in the right middle and lower lobes. There is no peripheral edema, and the client’s skin is warm and dry. The client has a productive cough with greenish sputum. He is alert and oriented but appears anxious.

Provider’s Prescriptions

• Continue enalapril 10 mg daily
• Acetaminophen 500 mg every 6 hours as needed for fever
• Increase oxygen to 3 L/min via nasal cannula if oxygen saturation drops below 90%
• Administer albuterol nebulizer treatment every 4 hours as needed for wheezing
• Encourage deep breathing and coughing exercises every hour

Question: Which actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.

The nurse is preparing a teaching plan for a group of well-educated clients who were found to be HIV positive within the last year. The nurse should explain that the human immunodeficiency virus (HIV) acts in which way to suppress the immune system?

When performing postural drainage on a client with chronic obstructive pulmonary disease (COPD), which approach should the nurse use?

The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

A client diagnosed with chronic obstructive pulmonary disease (COPD) is given a new prescription for tiotropium via an inhalation device. Which statement indicates the client understands the instructions for using this medication?

The nurse is caring for a client with chronic obstructive pulmonary disease who develops an onset of dyspnea and tachypnea with coughing. After positioning the client upright, which action should the nurse take next?

The client with Clostridium difficile in the stool receives a prescription for vancomycin PO. Which action should the nurse take before administering the first dose?

While changing a client’s postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client’s laboratory values?