A client with a facial fracture is receiving oxygen via a non-rebreather mask. Which assessment finding requires the nurse to take immediate action? 

A nurse is caring for a client post-laryngectomy due to head and neck cancer. What is the most important safety measure to implement when caring for this client? 

A nurse’s patient was admitted with this EKG.   The patient is prescribed an antiarrhythmic medication. What teaching should the nurse provide to the patient? 

The charge nurse is assigning tasks to the nursing team. Which task is appropriate to delegate to the LPN? 

A client with a suspected pulmonary embolism (PE) is undergoing diagnostic testing. Which of the following findings is most indicative of a PE? 

The nurse is educating a patient receiving IV heparin about potential side effects. Which statement by the patient indicates a need for further teaching? 

When managing a patient on mechanical ventilation, which action should the nurse prioritize? 

A client with head and neck cancer is receiving radiation therapy and reports difficulty swallowing. What is the priority nursing intervention?  

A chest tube is placed for a patient with pneumothorax. Which of the following is a critical action in managing the chest tube? 

The nurse cares for a 55-year-old female admitted to the burn unit following a house fire.    Nurses’ Notes    2000: A 55- year-old female arrives to the emergency department via ambulance with bilateral second and third degree burns to the front lower extremities from a house fire that occurred at 1800 today. Burns estimated at 36% of total body surface area. Client weighs 220 lbs.   2100:  Admitted to the burn unit. Vital signs as noted. Morphine sulfate given for pain.  Wound care was provided by the nurse.  Breath sounds clear.  Bilateral +2 pitting edema was noted in the lower extremities. Doppler pedal pulses present.  Vital Signs    Time  2000  2100  Temperature  37.8 C/100 F  37.5 C/99.5 F  Heart rate  130  135  Respirations  28  32  Blood pressure  88/58  80/54  Pulse oximeter  95 on 4L NC  92 on 4L NC  Pain  6/10  4/10  Intake & Output     Fluid resuscitation order: 4 mL Ringer’s lactate x kilogram weight x body surface burned. Give the first half within the first 24 hours and the remaining over the next 16 hours.     Hour  2000  2100  Fluids in the field  1200 mL/hr  1200 mL/hr  Output    20 mL        What should the nurse set the IV pump at to deliver the first 8 hours of fluid resuscitation for this patient according to the ordered fluid resuscitation order? ____  mL/hr