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A nurse is caring for a client who has benign prostatic hyperplasia (BPH). The nurse should expect which of the following findings?

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator-associated pneumonia?

A nurse is assessing a client who has hypothyroidism. Which of the following findings should the nurse expect?

A nurse is caring for a client who is receiving a continuous IV infusion of heparin. Which of the following actions should the nurse take?

A nurse is caring for a client who is receiving heat applications using an aquathermia pad. Which of the following actions should the nurse take when applying the pad?

A nurse is admitting a client who has pertussis. Which of the following types of transmission-based precautions should the nurse initiate?

A nurse is providing teaching to a client with a colostomy about appropriate food choices. Which of the following foods should the nurse include in the teaching?

A nurse is reviewing the laboratory test results from a client who has prerenal acute kidney injury (AKI). Which of the following electrolyte imbalances should the nurse expect?

A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the nurse’s responsibilities?

A nurse is caring for a client who is postoperative following a transurethral resection of the prostate. Which of the following complications is the priority for the nurse to monitor for?

A nurse is caring for a 73-year-old client in the emergency department (ED).

Medical History: Client was brought to the ED by their family member due to mental status changes. The family member reports that they visit the client every other day, and today the client did not initially realize who they were until several minutes after talking with them. The client has diabetes mellitus and takes insulin daily. A wound is noted on the right foot.

Nurses Notes: Family member reports that the client did not initially realize who they were when they went to visit. Client is currently somnolent but rouses to verbal stimuli and is oriented to person. Glasgow coma score is 13 and Modified Early Warning System (MEWS) score is 6. Respirations are even, unlabored, and deep, with few crackles noted in lung bases bilaterally with auscultation. Mucous membranes are dry and pink. Abdomen soft with hypoactive bowel sounds. Radial and pedal pulses are palpable, no edema noted. Skin is warm and dry. The right foot has a 2.5 cm x 3.3 cm (1 in x 1.3 in) superficial wound to the ball of the foot. The wound is moist with a scant amount of purulent drainage. Client stated they stepped on something last week while walking but did not notice a wound had occurred.

Client’s family member reports that the client takes 10 units of regular insulin subcutaneously every morning and 5 units every evening with the last dose taken this morning. Also states that the client took two aspirin yesterday for a headache.

Vital Signs:

• Temperature: 38.5°C (101.3°F)
• Pulse: 110/min
• Blood pressure: 98/60 mm Hg
• Respiratory rate: 26/min
• Oxygen saturation: 93% on 2 L nasal cannula
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Diagnostic Results:

• RBC count: 5.0 (Male 4.7 to 6.1)
• WBC count: 9,500/mm³ (5,000 to 10,000/mm³)
• Platelets: 97,000/mm³ (150,000 to 400,000/mm³)
• Hemoglobin: 15 g/dL (Male 14 to 18 g/dL)
• Hematocrit: 45% (Male 42% to 52%; Female 37% to 47%)
• Glucose: 186 mg/dL (74 to 106 mg/dL)

It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications: