A nurse is communicating the plan of care to an older client who has been admitted to the medical surgical unit. Which nursing actions facilitate this process? (Select all that apply.)

A nurse is in charge of a first-aid tent at an all-day outdoor sports event on a hot and humid day. A participant comes into the tent limping due to a calf cramp complaining of his heart racing, weakness, and nausea. What action would the nurse take first?

A client who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the client says, “I don’t need the aspirin today. I don’t have a fever.” Which action will the nurse take?

A client who has fallen from a roof is transported to the emergency department by ambulance. The client was unconscious at the scene but is conscious on arrival to the hospital. What is the priority assessment focus for this client?

A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether the athlete is developing postconcussion syndrome?

The nurse is preparing to administer a prescribed nebulizer dose of albuterol. Which statement by the client requires further evaluation before delivery of the medication?

A client in respiratory failure has been intubated and placed on mechanical ventilation. The client becomes very agitated and breathing asynchronously with the ventilation.  What is the priority action for the nurse?

Four hours after mechanical ventilation is initiated, a client’s arterial blood gas (ABG) results include a pH of 7.51, PaO2 of 82 mm Hg, PaCO2 of 26 mm Hg, and HCO3– of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to take which action?

The nurse is assessing a client with cardiogenic shock for evidence of multiple organ dysfunction syndrome.  Which new finding is the priority concern?

The nurse is caring for a client with Guillain-Barre syndrome. What will be the focus of nursing care? (Select all that apply.)