A 35-year-old man is brought to the emergency department after falling from a two-story building. He is diagnosed with a spinal cord injury at the cervical level. During the immediate postinjury period, the nurse plans the client’s care. What should be the primary focus of nursing management during this phase?

At 3 days old, a breastfed newborn is brought to the clinic because the parents notice yellowing of the baby’s skin and eyes. The infant is active, feeding well, and has no other symptoms. Laboratory testing reveals an indirect serum bilirubin level of 12 mg/dL. The nurse explains to the parents that this physiologic jaundice is a normal, temporary condition caused by:

The parents of a 2-day-old newborn receiving phototherapy for jaundice ask the nurse why their baby’s eyes are covered with patches. Before responding, the nurse understands that the primary reason for using the eye patches is to:

A client is being discharged home with a large abdominal wound that requires sterile dressing changes twice daily. During the teaching session, the nurse observes the family member perform a return demonstration of the dressing change. Which action by the family member indicates that further teaching is needed?

A 4-month-old infant diagnosed with hydrocephalus is being monitored in the pediatric unit. During assessment, the nurse observes several changes. Which finding should alert the nurse to suspect increasing intracranial pressure (ICP)?

A client has just returned to the surgical unit after a gastrectomy. The nurse notes that the nasogastric (NG) tube is draining a light-red liquid. For how long should the nurse expect this type of drainage to continue?

A client with severe hypokalemia is prescribed intravenous potassium chloride. The nurse prepares to administer the medication slowly and cautiously as ordered. This careful administration helps prevent which serious complication?

A client scheduled for a gastric bypass to treat morbid obesity asks the nurse about dietary changes to prevent complications after surgery. Which type of diet should the nurse teach the client to follow to minimize clinical manifestations of dumping syndrome?

A client returns to the surgical unit in the evening after undergoing a below-the-knee amputation. As the nurse plans evening care, which action should be implemented to promote recovery and prevent complications?

A client with paranoid-type schizophrenia is readmitted involuntarily after family members report that he threatened to harm them. During the initial interaction, the client angrily shouts, “You’re one of them. Leave me alone!” How should the nurse respond?

A client who delivered a baby 1 hour ago reports feeling that she is bleeding. Upon assessment, the nurse notes a steady trickle of blood from the vagina and that the fundus is soft. What should the nurse do first?

A client is on the first postoperative day after abdominal surgery. During assessment, the nurse notes changes in the client’s respiratory status. Which finding would support a diagnosis of atelectasis?

A 7-year-old child is admitted to the pediatric unit and is receiving chemotherapy for acute leukemia. Which nursing care measures are most important to implement while the child is on chemotherapeutic protocols?

A client undergoing chemotherapy is prescribed vinCRIStine. The nurse is reviewing the dietary plan with the client. Which dietary recommendation should the nurse expect to include to help minimize the side effects of vinCRIStine?

A 6-year-old child receiving chemotherapy has a very low platelet count. The nurse is monitoring the child closely. Which constituent in the urine should the nurse particularly observe for in this situation?

The parents of an 8-year-old child diagnosed with acute leukemia ask the nurse why their child needs radiation therapy to the spine and skull. How should the nurse respond most accurately?

During a follow-up visit, a nurse notes that an older adult client has not achieved the expected therapeutic outcome from a prescribed proprietary medication. When asked, the client reveals that the medication was never filled because of its cost. What is the nurse’s most appropriate action?

During a routine prenatal visit, a 28-week pregnant client tells the nurse, “I often get painful leg cramps at night.” Based on this information, what condition might the nurse suspect, and what recommendation should be provided to relieve it?

A 45-year-old woman is prescribed simvastatin (Zocor) 20 mg daily for elevated cholesterol and triglyceride levels. During the initial teaching session, what is the most important instruction the nurse should provide regarding the safe use of this medication?

A 7-year-old child with attention deficit/hyperactivity disorder (ADHD) is prescribed methylphenidate (Ritalin) to be taken with meals. When teaching the parents, what rationale should the nurse provide for administering the medication with food?

A client with acute respiratory distress syndrome (ARDS) is intubated and receiving mechanical ventilation in the ICU. What is an essential nursing intervention when caring for this client and the ventilator?

A client is admitted to the postanesthesia care unit (PACU) following thoracic surgery. A chest tube has been inserted and attached to a disposable plastic water-seal drainage system. What should the nurse do immediately after connecting the chest tube?

A client with schizophrenia has been experiencing auditory and visual hallucinations. During which situations should the nurse expect the hallucinations to be more frequent or intense?

A client who recently received a kidney transplant is prescribed cyclosporine (Gengraf) to prevent organ rejection. Which parameter should the nurse closely monitor to detect a serious adverse effect of this medication?

During her first prenatal visit at 23 weeks’ gestation, a woman reports a history of pica, such as eating nonfood substances like clay or ice. What is the nurse’s most appropriate action in response to this information?