The nurse is assigned to a patient with acute lymphocytic leukemia (ALL) about to undergo his first round of chemotherapy. The patient’s WBC is 120,000/uL and his LDH is 3 times the upper limit of normal. Which intervention is most important?

The 32-year-old patient presents to the emergency department complaining of difficulty breathing, cough, and chills. Vital signs are notable for a temperature of 38.4°C, heart rate 118 bpm, respiratory rate 24, oxygen saturation 87% on room air, and blood pressure of 98/62 mmHg. Upon assessment, the nurse notes nasal flaring, diminished breath sounds in the right upper lobe, and subcostal retractions. Capillary refill time is 4 seconds. The patient admits waking up in a pool of vomit after binge drinking 3 nights ago. Which orders does the nurse anticipate? Select all that apply.

The patient in the burn unit is being treated for third-degree burns that extend circumferentially around each arm up to the elbow. Which of the following physical assessments is most important for this patient?