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A nurse is evaluating a $68$-year-old client who underwent a left-sided thoracentesis $2$ hours ago for the treatment of a large pleural effusion secondary to heart failure. Which of the following assessment findings indicate a potential life-threatening complication and require immediate intervention? Select all that apply.

An emergency department nurse is caring for a school-aged child who presents with a spiral fracture of the humerus. The child's caregiver states, 'He just tripped and fell while running in the yard.' The child remains unusually quiet, avoids eye contact, and flinches when approached. Based on the ethical principle of nonmaleficence and legal mandates, which actions should the nurse take? Select all that apply.

A home healthcare nurse is conducting a follow-up visit for an 82-year-old client recovering from a fractured humerus. The client, who is alert and fully competent, lives with an adult grandchild. While the grandchild is in another room, the client tearfully states, "My grandchild got angry and shoved me against the wall, causing my arm to break. You must swear to keep this a secret. If you tell anyone, they will go to jail and I will be forced into a facility." Which of the following is the most appropriate response by the nurse?

Following notification of an impending unstable transfer from the intensive care unit, a charge nurse on a neurological step-down unit must rapidly reorganize care assignments. The available staffing mix includes a core neurological registered nurse (RN), a float RN from a general medical-surgical unit, an experienced licensed practical/vocational nurse (LPN/VN), and an unlicensed assistive personnel (UAP). Which delegation or assignment decision is most appropriate?

The surgical team is preparing an older adult client for an urgent appendectomy. The operating surgeon has reviewed the procedural risks, benefits, and alternatives with the client. When the registered nurse (RN) presents the informed consent document for a signature, the client exhibits resting hand tremors, profuse diaphoresis, and an elevated heart rate. The client pushes the paperwork away, stating, 'I cannot look at this until I get my morning vodka. I drink a pint every day to steady my nerves.' What is the most appropriate action for the RN to take?

An oncology charge nurse is asked to evaluate four clients simultaneously. Which client requires the most immediate assessment?

A nurse is planning care for a client with sepsis-induced delirium who repeatedly attempts to pull out their central venous catheter. Following unsuccessful attempts at verbal redirection and concealment of the line, the provider prescribes bilateral soft wrist restraints. Which actions should the nurse include in the client's care plan? Select all that apply.

A client on an acute oncology unit is scheduled for a bedside bone marrow aspiration and biopsy. The healthcare provider discussed the procedure and obtained the client's signature on the informed consent document earlier in the shift. As the nurse assists the client into the appropriate physical position, the client suddenly pulls away, begins crying, and states, 'I changed my mind. I cannot go through with this. Please stop.' The provider is in the room and is currently opening the sterile tray. Which of the following is the priority nursing action?

A unit charge nurse in an inpatient rehabilitation facility is evaluating the care plan for a client with exacerbating secondary progressive multiple sclerosis. The client's family reports three urgent concerns: the client frequently chokes on clear liquids, struggles to hold silverware or button clothing due to profound bilateral hand weakness, and the family feels overwhelmed and hopeless regarding the ongoing care demands. Which nursing action demonstrates the most appropriate interdisciplinary collaboration and safe delegation?

An ambulatory care nurse is counseling a 49-year-old client recently diagnosed with metabolic syndrome. The client reports working 60 hours a week, sleeping 4 to 5 hours a night, and eating mostly processed convenience foods. The client states, "I bought a gym membership and plan to do high-intensity interval training for two hours every day after work to fix my metabolism."

Which response by the nurse is the most appropriate?

A nurse in a community health clinic is developing a health promotion plan for a 65-year-old female client with a history of type 2 diabetes mellitus. During the assessment, the client states, "My mother had a severe stroke at my age, so I am very worried. I have also been occasionally losing my balance when walking, but I know feeling unsteady is just a normal part of getting older." Which of the following nursing actions represents the highest priority secondary prevention intervention for this client?

A home health nurse is developing a comprehensive self-care and health promotion plan for an older adult client who has advanced rheumatoid arthritis (RA), severe left-sided heart failure, and type 2 diabetes mellitus with advanced peripheral neuropathy. Which of the following interventions should the nurse include in the client's plan of care? Select all that apply.

A public health nurse is conducting a comprehensive physiological and functional assessment of an older adult client living independently in the community. Which of the following documented findings represent expected biological adaptations of senescence rather than pathological processes requiring acute medical intervention? Select all that apply.

A client who is admitted with severe gastrointestinal bleeding is receiving a unit of packed red blood cells (PRBCs) through a peripheral intravenous (IV) catheter. Fifteen minutes into the infusion, the client suddenly reports severe lower back pain, chills, and shortness of breath. The nurse suspects an acute hemolytic transfusion reaction. Place the following nursing interventions in the correct chronological order of priority from first to last.

A nurse is monitoring a client who recently underwent endoscopic band ligation for bleeding esophageal varices. Which assessment findings should the nurse identify as early indicators of systemic physiological deterioration and impending hypovolemic shock? (Select all that apply.)

A 79-year-old client with a documented history of mild cognitive impairment is scheduled for the elective placement of a permanent pacemaker. The client's legally appointed healthcare proxy signed the informed consent document the previous evening. While the registered nurse (RN) is preparing the client for transport to the catheterization laboratory, the client becomes tearful, grasps the RN's hand, and states, "Please don't let them put that metal box in my chest. My child is forcing me to do this so I live longer, but I am ready to pass on naturally." The client is currently oriented to person, place, and the immediate situation. What is the priority nursing action?

A client who recently underwent a total laryngectomy and permanent tracheostomy placement is preparing to return home. The client will require continuous enteral feedings and expresses significant anxiety about managing the new airway independently. Which collaborative actions should the nurse include in the interprofessional discharge plan? Select all that apply.

A 71-year-old client is preparing for a scheduled surgical intervention. The healthcare provider has conducted the preoperative briefing, and the nurse is present to witness the informed consent signature. Before signing the document, the client states, 'I am ready to sign, but I still do not understand what other treatment options I had.' Which action by the nurse represents the legally correct response?

An infection prevention nurse is conducting a unit audit and reviewing the current isolation protocols for four assigned clients. Match each client's clinical presentation to the most appropriate evidence-based infection control intervention.

A nurse in a college health clinic is assessing an 18-year-old client who admits to engaging in frequent binge drinking at weekend parties. Which initial response by the nurse is most appropriate?