RN Comprehensive Online Practice 2023 B

A nurse is teaching a pt who has opioid use disorder about methadone. which of the following information should the nurse include in the teaching? A. "If you suspect you are pregnant, stop taking this medication." B. "You cannot become physically dependent on this medication." C. "Sedation is a common adverse effect of this medication." D. "If you forget a dose, you can double your next dose."

C Sedation and drowsiness are common adverse effects of methadone. Sedation most frequently occurs at the beginning of treatment or during dosage increases.

A nurse is providing discharge instructions to a client following a total hip arthroplasty. Which of the following instructions should the nurse include? A. Minimize the use of a walker. B. Maintain the hip at an angle greater than 90°. C. Install a raised toilet seat at home. D. Place a pillow under the knees when lying down.

C The client should use a raised toilet seat at home to minimize hip flexion and prevent hip dislocation.

A nurse is planning to delegate client care tasks to assistive personnel. which of the following tasks should the nurse plan to delegate? A. provide instructions about client care to a family member over the phone. B. determine if the PRN pain med administered 30 mins ago has helped C. perform gastrostomy feedings through a clients gastrostomy tube. D. teach a client how to measure their own BP

C The nurse should delegate providing gastrostomy feedings through the client's established gastrostomy tube to an AP because this task is within the AP's range of function.

A nurse is providing colostomy care for a client using a two-piece pouching system. Which of the following actions should the nurse take? A. Cleanse the skin at the stoma site with povidone-iodine for 15 seconds. B. Dampen the skin before applying the skin barrier and ostomy pouch. C. Place the skin barrier over the stoma and hold it for 30 seconds. D. Cut the skin barrier opening 0.6 cm (0.24 in) larger than the stoma.

C. Place the skin barrier over the stoma and hold it for 30 seconds. The nurse should activate the adhesive in the skin barrier by holding it in place over the stoma for 30 seconds. INCORRECT: The nurse should cleanse the skin at the stoma site using a washcloth and warm water to reduce the risk of skin irritation. The nurse should thoroughly dry the skin around the stoma using a patting motion before applying the skin barrier to ensure the pouch adheres to the client's skin. The nurse should cut the skin barrier opening no more than 0.3 cm (0.12 in) larger than the stoma to reduce the risk of skin irritation.

a nurse is assessing a client following a vaginal delivery and notes heavy lochia and boggy fundus. which of the following meds should the nurse expect to administer? A. Nalbuphine B. terbutaline C. oxytocin D. mag sulfate

C. oxytocin The nurse should administer oxytocin, a hormone that stimulates uterine contractions, to decrease vaginal bleeding.

A nurse is developing a client education program about osteoporosis for older adult clients. The nurse should include which of the following variables as a risk factor for osteoporosis? A. obesity B. acromegaly C. estrogen dominance D. sedentary lifestyle

D A sedentary lifestyle is a risk factor for osteoporosis. The nurse should encourage older adult clients to engage in weight-bearing exercises because they will promote bone health by increasing calcium and phosphorus levels.

a charge nurse is observing a new nurse adminstering enteral feedings via NG tube. which of the following actions by the new nurse indicates an understanding of the procedure? A. Instills 100 mL of air into the NG tube after checking for residual B Flushes the NG tube with 0.9% sodium chloride irrigation every 2 hr c. Adds 20 mL of blue dye to each feeding to help detect aspiration D. Keeps the head of the bed elevated to 45° for 1 hr after feedings

D The nurse should keep the client's head elevated to 30° to 45° for 1 to 2 hr after feedings to decrease the risk for aspiration.

A nurse is interviewing a pt who is now without a home due to a natural disaster. After ensuring the client's safety, which of the following actions should the nurse take first? A. Assist the client with contacting individuals from the client's support system. B. Give the client information about available community resources for shelter. C. Suggest the client obtain mental health counseling. D. Determine the client's perception of the personal impact of the crisis.

D The first action the nurse should take using the nursing process is to assess the client. Therefore, the nurse should first determine the client's feelings and understanding of the natural disaster and its personal impact.

a home health nurse is caring for a group of older adults. the nurse should initiate a referral to a program of all-inclusive care for the elderly (PACE) for which client? A. client whose family requests hospital-based hospice care B. client who requires transfer to a skilled care facility C. client who qualifies for telehealth for pacemaker diagnostics D. client whose caregiver requests adults day care services

D The nurse should initiate a referral for PACE for this client because PACE provides adult day care services along with in-home assessments and supportive services.

A mental health nurse is conducting the first of several meetings with a client whose partner recently died. The nurse should perform which of the following actions to establish trust during the orientation phase of the nurse-client relationship? A. Encourage the client's problem-solving abilities. B. Discuss the client's previous experience with loss. C. Promote the client's self-esteem. D. Establish the termination date of therapy.

D. Establish the termination date of therapy. This task occurs in the orientation phase of a therapeutic relationship.

A charge nurse is preparing to administer 0900 medications and is told by the pharmacy staff that the medications are not available. Medication availability has been an ongoing problem, and the charge nurse has previously discussed this issue with the pharmacy staff. which of the following actions should they take first? A. document actual time of med admin B. notify risk manager C. complete incident report D. Inform the nurse manager of the issue

D. Inform the nurse manager of the issue The greatest risk to clients is injury from not receiving medications on time and developing a medical complication. Therefore, the priority intervention the charge nurse should take is to follow the chain of command and contact the nurse manager.

A nurse manager is preparing an educational session for nursing staff about how to provide cost-effective care. Which of the following methods should the nurse include in the teaching?

Delegate non-nursing tasks to ancillary staff. Delegating non-nursing tasks to ancillary staff is an effective method of providing high-quality, cost-effective care because this will allow additional time for nurses to focus on skilled tasks.

A nurse is updating the plan of care for a client who is 48 hr postoperative following a laryngectomy and is unable to speak. Which of the following actions should the nurse plan to take first?

Determine the client's reading skills. The first action the nurse should take when using the nursing process is to assess the client. By determining the client's level of reading skills and cognition, the nurse can best provide the client with a variety of customized techniques to practice and use after verbal skills are lost.

A nurse in an emergency department is preparing to discharge a client who has experienced intimate partner violence. Which of the following actions should the nurse take first?

Develop a safety plan with the client. The greatest risk to this client is injury from violence. Therefore, the first action the nurse should take is to develop a safety plan with the client.

A nurse in an emergency department is assessing a client who reports taking methylenedioxymethamphetamine (MDMA). Which of the following findings should the nurse expect?

Diaphoresis Diaphoresis is an expected finding of MDMA use. Additionally, the client might experience increased tactile sensitivity, lowered inhibition, chills, muscle cramping, teeth clenching, and mild hallucinogenic effects.

A nurse on a medical-surgical unit is assessing a client who has had a stroke. For which of the following findings should the nurse initiate a referral for occupational therapy?

Difficulty performing ADLs The nurse should initiate a referral for occupational therapy to teach the client the skills necessary to become independent in performing ADLs such as bathing, dressing, or eating.

History and Physical 2 months ago: Client presented to clinic for routine visit. Client reported feeling tired at times but getting through the workday and walking after work. Reported chronic nonproductive cough. Smokes 1.5 packs of cigarettes per day. Today, 1030: Client reports fatigue over the past several days, spending more time in bed. Reports chronic productive cough with blood-tinged sputum this morning. Smokes 1 pack of cigarettes per day. Client takes lisinopril 20 mg PO daily, atorvastatin 20 mg PO daily. Assessment 2 months ago: Client states, "I sleep in my recliner and that works great." Skin is warm, dry. Lungs clear to auscultation. Chronic nonproductive cough. Abdomen soft, nondistended. Bowel sounds present. Slight edema in feet bilaterally. Today, 1030: Client states, "I can't catch my breath." Skin pale. Respirations labored. Crackles present in left-lower lobe. Coughing during assessment. Blood

For each assessment finding noted above, click to specify if the finding is expected of pneumonia, COPD, or heart failure. Pneumonia = tobacco use, elevated WBC, productive cough w/ sputum, inc temp, dec O2, resp acidosis COPD = tobacco use, dec O2 sat HF = tobacco use, BNP level, dec O2 sat

A nurse is caring for a client who has abdominal pain. Nurses' Notes 0900: Client reports loss of appetite, weight loss, and fatigue for 1 week. Reports abdominal pain, 6 on a scale from 0 to 10, for 2 days. Client is a perioperative nurse, returned 1 week ago from a 2-week mission trip to an underdeveloped country. 1200: Results of antibody studies obtained. Provider prescription for antiviral medication pending. Physical Examination 0930: Lung sounds clear bilaterally. Skin warm to touch and jaundiced. Dry skin noted on extremities. Sclera yellow bilaterally. Bowel sounds normoactive in four quadrants. Client reports right upper quadrant pain upon palpation. Urine specimen obtained for urinalysis, dark yellow in color. Vital Signs 0900: Temperature 36.9° C (98.5° F) Heart rate 84/min Respiratory rate 18/min Blood pressure 118/78 mm Hg Oxygen saturation 98% on room air Diagnostic Results 1100: Aspartate aminot

For each condition, click to specify if the characteristic is consistent with an acute infection of hepatitis A, hepatitis B, or hepatitis C. Each characteristic may support more than one disease process. Manifestations of Hep A, Hep B, & Hep C = jaundice, yellow sclera, RUQ pain on palpation, dark yellow urine, inc AST & ALT levels Hep A = risk from fecal-oral transmission (recent travel to underdeveloped country & occupational risk) Hep B & Hep C = bloodborne transmission Hep B, & C = antiviral medication

A nurse is caring for a client who is pregnant. Nurses' Notes 1000: The client reports repeated episodes of vomiting and two episodes of diarrhea in past 24 hr. Client is at 18 weeks of gestation and reports a history of nausea and vomiting for the past 12 weeks.1015: IV fluids initiated. Prochlorperazine administered via intermittent IV bolus.1100: Client reports improvement in nausea. Ice chips provided. Client voided 50 mL of dark yellow urine.1500: Client tolerating fluids well. Ate four graham crackers without emesis. Has voided 300 mL of amber-colored urine.

For each discharge instruction, click to specify if each action is recommended or contraindicated for the client. When taking action and providing discharge teaching for a client who has hyperemesis gravidarum, the nurse should recommend the client should eat every 2 to 3 hr to avoid having an empty stomach, which can increase nausea. The client should separate liquids from solids every 2 to 3 hr to help minimize nausea. The client should eat foods high in protein that are low in fat. Warm ginger ale or ginger tea can also decrease nausea. contraindicated = increase intake of high fat foods

A nurse is teaching a client who has a new prescription for total parenteral nutrition through a central line. Which of the following information should the nurse include in the teaching?

"I will need to measure your weight daily."

A nurse is providing teaching to the guardians of a newborn about measures to prevent sudden unexpected infant death (SUID). Which of the following guardian statements indicates an understanding of the teaching?

"I will not allow anyone to smoke near my baby." This statement by the guardian indicates an understanding of the nurse's instructions. Research indicates a strong correlation between exposure to cigarette smoke and the occurrence of SUID.

A charge nurse notices that one of the nurses on the shift frequently violates unit policies by taking an extended amount of time for break. Which of the following statements should the charge nurse make to address this conflict?

"I would like to talk to you about the unit policies regarding break time." The charge nurse is dealing with the conflict in a cooperative, positive manner by using this statement to open the conversation in a nonthreatening way. The focus is on the length of the break time and is not a personal affront.

A nurse is caring for an adolescent client who has a new diagnosis of terminal cancer. When discussing the client's prognosis with the parents, the nurse should recognize which of the following responses by the parents as an example of rationalization?

"Maybe this is better for our child because we don't want any suffering through chemotherapy treatments." By justifying the adolescent's prognosis by searching for a more personally acceptable explanation for the impending loss, the parent is using the defense mechanism of rationalization.

A nurse is providing teaching about lithium to a client who has bipolar disorder. Which of the following statements should the nurse include in the teaching?

"Notify your provider if you experience increased thirst." The nurse should recognize that an increase in thirst is a manifestation of lithium toxicity. The nurse should instruct the client to report increased thirst, vomiting, diarrhea, or tremors to the provider.

A nurse is caring for a client who is at 28 weeks of gestation. The client asks the nurse to explain what is causing the constipation. Which of the following responses should the nurse make?

"The enlarged uterus compresses the intestines and causes constipation." During the second and third trimesters, the size and weight of the growing uterus cause both displacement and compression of the intestines. These changes cause a decrease in motility, leading to constipation.

A nurse is providing teaching to a client who is at 24 weeks of gestation and is scheduled for a 3-hr oral glucose tolerance test. Which of the following instructions should the nurse include in the teaching?

"You will need to fast the night before the test." The nurse should instruct the client that they will need to fast the night before the test to prevent inaccurate test results.

A nurse is caring for a toddler who is admitted to the pediatric unit for surgery. Which of the following should the nurse include in the toddler's plan of care? A. Encourage the parents to bring toys from home. B. Use a visual analog scale to rate the toddler's pain. C. Inform the toddler about the procedure 1 week before hospitalization. D. Stress to the parents the need for maintaining the hospital's daily routine.

A To help decrease the toddler's anxiety, the nurse should encourage the family to bring familiar objects from home, such as toys, blankets, and feeding utensils.

A nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster. Which of the following clients should the nurse recommend for discharge?

A client who has cellulitis and is receiving oral antibiotics every 8 hr

A case manager is reviewing the medical records of several clients. For which of the following clients should the nurse request an interprofessional care conference?

A client who has diabetes mellitus and has had repeated hospitalizations for diabetic ketoacidosis A client who is having repeated episodes of a life-threatening complication requires an interprofessional care conference so team members can address the client's needs to provide care and support.

A nurse is caring for multiple clients in an antepartum clinic. For which of the following clients should the nurse plan to perform fetal heart monitoring? (Select all that apply.)

A client who has premature rupture of membranes is correct. Clients who have premature rupture of membranes require fetal monitoring to assess and evaluate fetal well-being. A client who reports decreased fetal movement is correct. Clients who report decreased fetal movement require fetal monitoring to assess and evaluate fetal well-being. A client who has gestational hypertension is correct. Clients who have gestational hypertension require fetal monitoring to assess and evaluate fetal well-being.

A community health nurse is performing triage tagging following a mass casualty incident. On which of the following clients should the nurse place a black tag?

A client who has significant head trauma and agonal respirations The nurse should place a black tag on a client who has significant head trauma and agonal respirations because this client is not likely to recover or will require extensive resources for care.

An antepartum nurse is caring for four clients. For which of the following clients should the nurse initiate seizure precautions?

A client who is at 33 weeks of gestation and has severe gestational hypertension The nurse should initiate seizure precautions for a client who has severe gestational hypertension because an extremely elevated blood pressure in an antepartum client can trigger seizure activity. The nurse should provide the client with a quiet, darkened environment, place suction equipment and oxygen at the bedside, and position the call light within the client's reach.

A nurse is caring for four clients at the beginning of a shift. After receiving change-of-shift report, which of the following clients should the nurse attend to first?

A client who is confused and has been attempting to get out of bed The nurse should recognize that a client who is confused and has been attempting to get out of bed is at greatest risk for injury from a fall. Therefore, the nurse should attend to this client first.

A nurse has received change-of-shift report on four assigned clients. For which of the following clients should the nurse intervene to prevent a potential food and medication interaction?

A client who is receiving an MAOI and is requesting a cheeseburger for dinner This client's food selection contains tyramine. Clients prescribed an MAOI must restrict intake of foods that contain tyramine due to adverse effects, such as hypertension.

A nurse is assessing an older adult client who has pneumonia. Which of the following findings should the nurse expect?

Acute confusion An older adult client who has pneumonia will also typically have acute confusion, fatigue, lethargy, and anorexia.

Medication Record Digoxin 0.25 mg PO daily Potassium chloride 20 mEq/L PO daily Metformin 500 mg PO daily Furosemide 20 mg PO daily Vital Signs Blood pressure 116/62 mm Hg Respiratory rate 18/min Temperature 37.3° C (99.1° F)Apical heart rate 62/min Daily weight 84.82 kg (187 lb) (gain of 0.6 lb in 24 hr) Laboratory Results Digoxin 0.78 ng/mL Potassium 3.7 mEq/L Glucose 85 mg/dL A nurse is planning morning care for a client who has heart disease and type 2 diabetes mellitus. Upon review of the client's medical record, which of the following actions should the nurse take?

Administer daily medications. The client's vital signs and laboratory data are within the expected reference range. Therefore, the nurse should administer the client's daily medications.

A nurse manager is preparing an educational session about advocacy to a group of nurses. The nurse manager should include which of the following information in the teaching?

Advocacy is a leadership role that helps others to self-actualize.

A nurse is caring for an older adult client who is experiencing chronic anorexia and is receiving enteral tube feedings. Which of the following laboratory values indicates the client needs additional nutrients added to the feeding?

Albumin 2.8 g/dL (3.5 to 5 g/dL) The nurse should recognize that an albumin level of less than 3.5 g/dL indicates malnutrition and a need for additional nutritional supplementation.

A nurse is caring for a client who has become aggressive and potentially violent. Which of the following actions should the nurse take?

Allow the client time for reflection and decision making. The nurse should allow the client silence and time to reflect on what is occurring as well as what decision they would like to make moving forward. Clients might feel more stressed if they feel they are being rushed, which can increase the chance of violent behavior.

A nurse is performing tracheostomy care for a client who is postoperative following a laryngectomy. Which of the following actions should the nurse take when suctioning the client's airway?

Apply suction for 10 seconds. The nurse should apply suction for only 5 to 15 seconds to minimize oxygen loss.

A nurse working on a medical-surgical unit receives a telephone call requesting the status of a client from an individual who identifies themselves as the client's guardian. Which of the following actions should the nurse take?

Ask the caller for verification of their identity. According to HIPAA, if someone requests information about a client, it is the nurse's duty to protect that information. Therefore, the nurse should inform the caller that nurses cannot release any client information over the phone without the permission of the client. The nurse should ask for verification of the caller's identity to determine if they have been authorized by the client to receive information.

A nurse is caring for a client who has sensorineural hearing loss and is helping them choose items for their meal tray. Which of the following techniques should the nurse use to help the client communicate their choices?

Ask the client to point to items on a picture menu. The nurse should recognize that using visual aids can help the client communicate their meal choices. The use of a visual aid, like a picture menu, can ensure the client understands the meal choices.

A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is the nurse's priority?

Assist with deep breathing and coughing. The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to assist the client with deep breathing and coughing, which reduces the risk for postoperative pneumonia.

A nurse is caring for an older adult client in the PACU following general anesthesia. Which of the following findings should the nurse report to the provider?

Audible stridor Audible stridor, or a high-pitched sound heard in the client's airway, indicates edema, laryngeal spasm, secretions, or some type of airway obstruction that could become life-threatening. The nurse should report this finding to the provider.

A nurse is planning care for a client who is receiving hemodialysis via an established arteriovenous (AV) fistula in the right arm. Which of the following interventions should the nurse include in the client's plan of care?

Auscultate the affected extremity for a bruit. The nurse should auscultate the AV fistula every 4 hr to ensure a bruit is present, which indicates patency.

A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?

Auscultate the apical pulse at least 1 min. The nurse should auscultate the apical pulse to obtain an accurate assessment of heart rate and rhythm. Auscultation of a newborn's heart sounds can be difficult because of the rapid rate and the transmission of respiratory sounds.

A nurse manager is reviewing clients' rights with the nurses on the unit. The nurse manager should tell the nurses that informed consent promotes which of the following ethical principles?

Autonomy Autonomy refers to a client's ability to make their own decisions about treatment. Informed consent promotes autonomy by providing clients with complete information about treatment.

A nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following interventions should the nurse include in the plan?

Avoid including raw fruits in the client's diet. The nurse should exclude raw fruits and vegetables from the client's diet to reduce the risk of bacterial infections.

A nurse in a provider's office is assessing an adolescent who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Which of the following questions should the nurse ask to assess for an adverse effect of this medication? A. "Have you experienced muscle stiffness?" B. "Have you had any stomach pain or bloody stools?" C. "Have you experienced a dry cough?" D. "Have you noticed an increase in urine output?"

B The nurse should ask the client about the presence of stomach pain or bloody stools, which is an indication of gastrointestinal bleeding, an adverse effect of ibuprofen.

A nurse is reviewing the ABG results of a client who has COPD. The results include a pH of 7.3 (7.35 to 7.45), PaO2 56 mm Hg (80 to 100 mm Hg), PaCO2 54 mm Hg (35 to 45 mm Hg), HCO3- 26 mEq/L (21 to 28 mEq/L), and SaO2 87%. Which of the following is the correct interpretation of these values? A. Uncompensated metabolic acidosis B. Uncompensated respiratory acidosis C. Compensated respiratory acidosis D. Compensated metabolic acidosis

B A pH of 7.3 is below the expected reference range and indicates the client has acidosis. A PaCO2 of 54 mm Hg is above the expected reference range, which indicates the acidosis has a respiratory origin when combined with the low pH. The HCO3- of 26 mEq/L is within the expected reference range, indicating that the acidosis is not metabolic in origin and the body has not yet corrected the imbalance through compensation.

when caring for a child, a nurse plans to use nonpharmacological interventions to enhance the effectiveness of pain meds. which of the following strategies incorporates visualization techniques to help dec the child's discomfort?

Blowing bubbles with liquid soap to "blow the hurt away" Having the child blow bubbles is a visualization technique that can help to decrease the child's discomfort. The child can visualize the pain as the bubble that they blow away from themself and into the air.

A nurse is assessing a client who has major depressive disorder and is taking amitriptyline. Which of the following findings should the nurse identify as an adverse effect of the medication?

Blurred vision The nurse should identify blurred vision as an adverse effect of amitriptyline and notify the provider.

A nurse in a mental health clinic is assessing a client who has a history of seeking counseling for relationship problems. The client shows the nurse multiple superficial self-inflicted lacerations on their forearms. The nurse should identify these behaviors as characteristics of which of the following personality disorders?

Borderline The nurse should identify that clients who have borderline personality disorder tend to be emotionally unstable, have troubled interpersonal relationships, and often engage in harmful behaviors such as cutting, substance use, and suicidal ideation.

Nurses' Notes Day 1, 1000: Client presents to the emergency department (ED) with right-sided hemiparesis, lethargy, and aphasia. The client's symptoms started 1 hr prior to arrival at the ED. Client received fibrinolytic therapy and was transferred to the ICU. Day 2, 0800: Client is awake and alert to person, place, and time. Client has weak right-side hand grasp. However, this is improved from admission. Client to be evaluated by speech therapy due to aphasia. Day 2, 1930: Called to the client's room by a family member. Client is lethargic and restless, oriented to person and place. Client reports headache. The client's family member also reports that the client just vomited in an emesis basin. Client's speech is slurred. Vital Signs Day 1,1000: Temperature 37.2° C (99° F) Heart rate 114/min Blood pressure 184/88 mm Hg Respiratory rate 24/min Oxygen saturation 97% on 2 L via nasal cannula Day 2, 0800: Temperature

For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client. When generating solutions, the nurse should identify that oxygen therapy, monitoring blood glucose, and keeping lights in the client's room dim are anticipated prescriptions. The client is exhibiting manifestations of increased intracranial pressure (ICP). Therefore, the nurse should titrate oxygen therapy to maintain the oxygen saturation level above 95% and avoid hypoxia. The nurse should frequently monitor the client's vital signs and blood glucose to avoid secondary brain injury. The nurse should also dim the lights in the client's room, because many clients who have increased ICP experience photophobia.

A nurse in a provider's office is caring for a client. Nurses' Notes Day 1, 0900: Client is 65-year-old who reports pain and burning on urination.Client states, "I am having trouble making it to the bathroom on time and I'm up throughout the night needing to urinate." Client alert and oriented to person, place, and time.Bilateral breath sounds clear. Respirations even and unlabored.S​3 auscultated. Lower extremity edema +1. Radial and pedal pulses +2.Bowel sounds normoactive. Client reports no nausea or vomiting.Client has a history of type 2 diabetes mellitus, hypertension, and COPD. The nurse is planning to teach the client how to prevent further UTIs from occurring. Which of the following instructions should the nurse plan to include? Drink approximately 4 L of fluids daily. Void every 4 to 6 hr during the day. Drink orange juice daily. Gently cleanse the perineum before intercourse.

Gently cleanse the perineum before intercourse. When generating solutions, the nurse should educate the client on how to prevent future UTIs by cleansing the perineum prior to intercourse. During intercourse, bacteria from the skin can enter the urinary tract, causing infection.

A nurse is caring for a client who has active tuberculosis (TB). Which of the following actions should the nurse plan to take to prevent the transmission of the disease?

Have the client wear a surgical mask while being transported outside the room.

A nurse is assessing a school-age child who has cystic fibrosis. Which of the following findings is the priority for the nurse to report to the provider?

Hemoptysis 275 mL/24 hr Hemoptysis greater than 250 mL/24 hr indicates that this child is at greatest risk for hemorrhage. Therefore, this is the priority finding for the nurse to report.

A nurse in an emergency department is caring for a child who has a fever and fluid-filled vesicles on the trunk and extremities. Which of the following interventions should the nurse identify as the priority?

Initiate transmission-based precautions. When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority action is to initiate transmission-based precautions for the child. The child most likely has varicella. Therefore, the nurse should isolate the child to prevent the spread of the infection.

A nurse is preparing to administer 15 units of regular insulin along with 20 units of NPH insulin. Which of the following actions should the nurse plan to take?

Inject 20 units of air into the NPH insulin vial. The nurse should inject 20 units of air into the NPH insulin vial and withdraw the needle without touching the insulin, then proceed to inject 15 units of air into the regular insulin vial.

A nurse is caring for a client who is taking valproic acid for seizure control. For which of the following adverse effects should the nurse monitor and report?

Jaundice The nurse should monitor the client for jaundice and report any indication to the provider. Clients who take valproic acid are at risk for liver damage, which can lead to jaundice.

A nurse is assessing a client who has antisocial personality disorder. Which of the following manifestations should the nurse expect?

Lack of remorse A client who has antisocial personality disorder is more likely to show a lack of remorse.

A nurse manager is preparing a newly licensed nurse's performance appraisal. Which of the following methods should the nurse manager use to evaluate the nurse's time management skills?

Maintain regular notes about the nurse's time management skills. Maintaining notes over a period of time provides a comprehensive view of the nurse's abilities, so the manager can identify trends in the nurse's overall performance.

A nurse on a medical-surgical unit is caring for a client who has a new diagnosis of terminal cancer. The client tells the nurse that they would like to go home to be with family and loved ones. Which of the following actions should the nurse take?

Make a referral for social services. As a client advocate, the nurse should support the client's decisions and obtain a referral for social services to ensure that the client's needs at home are met. Social services can set up home care or hospice care services for the client if needed.

A nurse is caring for a client who has fluid volume overload. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Measure the client's daily weight. It is within the AP's range of function to measure a client's daily weight, so the nurse should delegate this task to the AP.

A nurse working on an inpatient mental health unit is caring for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse recommend including in the plan of care to ensure a safe client care environment?

Observe the client every 15 min. The nurse should observe the client who is experiencing mania every 15 minutes. Frequent observation allows the nurse to identify behaviors that need redirection and to protect the safety of the client and others.

A nurse is assessing a client who has a chest tube. Which of the following findings should the nurse expect?

Occlusive dressing on the insertion site An occlusive dressing on the insertion site prevents air from leaking and is an expected finding.

A nurse is caring for a client who is immediately postoperative following a subtotal thyroidectomy. Vital Signs 1100: Temperature 37.4° C (99.4° F) Heart rate 98/min Respiratory rate 18/min Blood pressure 128/68 mm Hg Oxygen saturation 97% on room air 1115: Temperature 37.8° C (100.1° F) Heart rate 110/min Respiratory rate 16/min Blood pressure 138/74 mm Hg Pulse oximetry 95% on room air 1130: Temperature 38.6° C (101.5° F) Heart rate 136/min Respiratory rate 16/min Blood pressure 154/86 mm Hg Oxygen saturation 95% on 2 L/min via nasal cannula Medication Administration Record 1110: Morphine 4 mg IV bolus Nurses' Notes 1100: The client is asleep, easily aroused. Rates pain at incision site as 8 on a scale of 0 to 10. Portable wound bulb suction device in place with scant serosanguinous drainage present. Dressing to neck dry and intact. 1115: Client asleep. Arousable with name called loudly multiple times. Cl

Select the 4 client findings that lead the nurse to suspect that the client is experiencing thyroid storm. When analyzing cues, the nurse should identify that thyroid storm can be caused by trauma to the thyroid gland, such as surgery, and excessive release of thyroid hormone greatly increases the metabolic rate. Fever greater than 38.5° C (101.3° F), heart rate greater than 130/min, systolic hypertension, and mental status changes, such as confusion, restlessness, and sleepiness, are characteristic of thyroid storm.

A nurse is caring for a client who has a fractured femur and has had a fiberglass leg cylinder cast for 24 hr. Which of the following assessment findings should the nurse identify as the priority?

The client's heel is reddened and tender. The greatest risk to this client is injury from a pressure ulcer. Therefore, the priority assessment finding the nurse should identify is a reddened and tender heel.

A nurse is caring for an adolescent in the emergency department (ED). Nurses' Notes 0700: Adolescent admitted to ED. Adolescent's parents are concerned about left leg injury that appears to be getting worse. Parents report adolescent has had fever, decreased appetite, and decreased energy within the past 2 days. Adolescent reports leg injury occurred while playing soccer. 0715: Adolescent is alert and oriented to person, place, time, and situation. Adolescent reports left lower leg pain as 4 on a scale of 0 to 10.Heart rate regular. Capillary refill less than 3 seconds. Respirations even, unlabored. Lungs clear anterior/posterior. Abdomen soft, nondistended. Bowel sounds hyperactive in all 4 quadrants. Pedal pulses +2 bilaterally. Medial lateral aspect of left lower leg: 3 x 3 cm2 area of redness with small pustules present. Tenderness and warmth noted to the area.

The nurse is reviewing the adolescent's electronic medical record (EMR). Which of the following findings requires immediate follow up by the nurse? the nurse should identify that the adolescent has a potential skin infection, such as cellulitis. The skin assessment reveals that the medial lateral aspect of the left leg has a 3 x 3 cm2 area of redness with small pustules, tenderness, and warmth, which can indicate infection. The adolescent's temperature and WBC count are above the expected reference range, which can also indicate infection. The adolescent's casual blood glucose and potassium are above the expected reference range, which can indicate infection or a complication of type 1 diabetes mellitus. The nurse should immediately follow up on these findings because they can indicate infection or other complications.medial-lateral

A nurse is caring for a client who is on the spinal cord injury (SCI) unit. Nurses' Notes Day 3, 1700: Client admitted to SCI unit 3 days ago following C7 injury. Skin is cool, pale, and dry to touch. Respirations easy and unlabored. Lung sounds diminished in lower lobes. Abdomen soft and nondistended with active bowel sounds. Client passed a small amount of hard formed stool this AM. Indwelling urinary catheter draining clear yellow urine. Deep tendon reflexes (DTR) are biceps 1+, triceps 1+, patella 0, and ankle 0 bilaterally. Client reports pain of 0 on a 0 to 10 scale. Day 4, 0600: Client reports increased coughing and shortness of breath. Crackles auscultated in lower lobes bilaterally. Face and neck flushed. Skin warm and moist. Client reports blurred vision and a headache as an 8 on a 0 to 10 pain scale. Abdomen soft and mildly distended. Hypoactive bowel sounds present. Urinary output 300 mL over last 8 hr.

The nurse should analyze cues from the client's manifestations and determine that the client is most likely experiencing manifestations of pneumonia and autonomic dysreflexia. A client who has a cervical SCI is at risk for respiratory complications because spinal innervation to the respiratory muscles is disrupted. Adventitious breath sounds in the lower lobes bilaterally and a decrease in oxygen saturation to less than 92% can indicate pneumonia. The client's sudden increase in blood pressure, bradycardia, flushing of the skin above the area of the injury, headache, and blurred vision are manifestations of autonomic dysreflexia, which can be a life-threatening condition.

A nurse is caring for a client who is postoperative following coronary artery bypass surgery (CABG). Laboratory Results 0630: Sodium 145 mEq/L (136 to 145 mEq/L) Potassium 3.2 mEq/L (3.5 to 5 mEq/L)Chloride 116 mEq/L (98 to 106 mEq/L)BUN 24 mg/dL (10 to 20 mg/dL)Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L)Total calcium 9 mg/dL (9 to 10.5 mg/dL)Phosphate 4.6 mg/dL (3 to 4.5 mg/dL)Glucose 95 mg/dL (74 to 106 mg/dL) WBC count 9,500/mm3 (5,000 to 10,000/mm3​) I&O 0700: 4 hr input 400 mL4 hr output 350 mL1100: 4 hr input 475 mL4 hr output 360 mL1500: 4 hr input 350 mL4 hr output 375 mL Vital Signs 0700: Temperature 37.6° C (99.6° F)Heart rate 86/minRespiratory rate 20/minBlood pressure 115/70 mm HgOxygen saturation 100% on 2 L via nasal cannula 1100: Temperature 37.2° C (99° F)Heart rate 88/minRespiratory rate 18/minBlood pressure 110/72 mm HgOxygen saturation 100% on 2 L via nasal cannula1500: Temperature 37.7° C (99

The nurse should analyze cues to determine the client is at greatest risk for developing dysrhythmias related to hypokalemia, as evidenced by the laboratory report and the client's report of muscle cramping. Potassium and magnesium depletion are common manifestations in clients who are postoperative following CABG. Due to medication or hemodilution, it is important for the nurse to closely monitor electrolytes.

A nurse is caring for a 5-year-old child. Physical Examination 1510: Upon visual inspection, throat is inflamed, tonsils appear pink, reddened and epiglottis is edematous and cherry red in appearance. Skin appears pale. Stridor noted upon inspiration with diminished bilateral lung sounds. 1500: Child accompanied to emergency department by caregiver. Caregiver states child has a sore throat and reports the child has "pain on swallowing" and denies cough. Child is agitated and leaning forward with drooling noted. 1505: Axillary temperature 38.8° C (102° F)Heart rate 130/minRespiratory rate 28/minBlood pressure 99/58 mm HgOxygen saturation 90% on room air

The nurse should anticipate initiating droplet precautions and requesting a prescription for IV antibiotics. The child is most likely experiencing epiglottitis because of the clinical manifestations of a high fever, inflammation and redness of the throat, pale skin, stridor with inspiration, painful swallowing, no cough, is sitting in tripod position, and drooling. The nurse should monitor the child's temperature and breath sounds.

A nurse in a provider's office is caring for a client. Provider Prescriptions Day 1, 0930: Collect urine specimen for urinalysis and urine culture and sensitivity. Trimethoprim/sulfamethoxazole 160/800 mg PO twice daily for 10 days Phenazopyridine 200 mg PO every 6 hr for 2 days

The nurse should determine that the priority hypothesis is the client is at the highest risk for developing pyelonephritis as evidenced by the client's urinalysis results. The urinalysis indicates dark cloudy urine, increased specific gravity, increased pH, increased red and white blood cells, positive nitrites, positive leukocytes, and trace amounts of blood, which indicate a urinary tract infection (UTI). If left untreated, a UTI can lead to pyelonephritis.

A nurse is caring for a client who has a new diagnosis of anorexia nervosa. Vital Signs Day 1, 2005: Temperature 35.3° C (95.5° F) Heart rate 60/min Respiratory rate 23/min Blood pressure 90/55 mm Hg Oxygen saturation 98% on room air Day 2, 0800: Temperature 36.1° C (97° F) Heart rate 65/min Respiratory rate 20/min Blood pressure 88/57 mm Hg Oxygen saturation 98% on room air Graphic Record Day 1, 2005: Weight 37.5 kg (82.7 lb) Height 162.56 cm (64 in) BMI 14.2 Day 2, 0800: Weight 37.4 kg (82.5 lb) BMI 14.1 Laboratory Results Day 1, 2030: Sodium 146 mEq/L (136 to 145 mEq/L) Potassium 3.3 mEq/L (3.5 to 5 mEq/L) Chloride 110 mEq/L (98 to 106 mEq/L) BUN 21 mg/dL (10 to 20 mg/dL ) Magnesium 1.2 mEq/L (1.3 to 2.1 mEq/L) Phosphate 2.8 mg/dL (3 to 4.5 mg/dL) Glucose (casual) 75 mg/dL (74 to 106 mg/dL) Total protein 5.8 g/dL (6.4 to 8.3 g/dL) Albumin 3 g/dL (3.5 to 5 g/dL) Day 2, 0530: Sodium 150 mEq/L (136 to

The nurse should first address the client's electrolyte imbalance, followed by the client's fear of weight gain. When analyzing cues, the nurse should first address the client's electrolyte imbalance. The client has hypokalemia, which increases the risk for cardiac arrhythmias. Once the client's medical concerns are addressed, the nurse should then focus on the underlying psychological issues behind the eating disorder, such as the client's fear of weight gain.

A nurse in an emergency department is caring for a client who is at 9 weeks of gestation and reports nausea and vomiting for the past 2 days. Which of the following findings should the nurse expect?

The nurse should recognize the client's urine specific gravity is significantly elevated above the expected reference range of 1.005 to 1.03 if a client at 9 weeks gestation reports nausea and vomiting for the past 2 days. An increased urine specific gravity indicates dehydration from vomiting.

A nurse is caring for a client who has a prescription for a continuous passive motion (CPM) machine following a total knee arthroplasty. Which of the following actions should the nurse take?

Turn off the CPM machine during mealtime. The nurse should turn off the CPM machine during meals to promote client comfort and dietary intake.

A nurse in an emergency department (ED) is assessing a client. Medical History 1030: Diagnosed with schizophrenia 2 years ago Migraine headaches Unresponsive to second-generation medications (clozapine and risperidone), changed to first-generation medication 6 months agoCurrent medications: Haloperidol 5 mg PO TIDSumatriptan 50 mg PO every 2 hr PRN headache

Upon recognizing and analyzing the client cues of decreased responsiveness, muscle rigidity, posturing, diaphoresis, and vital signs that are outside the expected reference ranges, the nurse's priority hypotheses should be that this client is most likely experiencing neuroleptic malignant syndrome, which is related to the client's haloperidol therapy. It is important to generate solutions and take actions that will decrease the client's temperature, blood pressure, heart rate, and respiratory status, which will improve the client's neurological status. The nurse should hold the client's antipsychotic medications and apply a cooling blanket to reduce the client's temperature. Neuroleptic malignant syndrome is a life-threatening condition. Therefore, the nurse should monitor the client's laboratory and arterial blood gas values as multiorgan failure can occur. To evaluate interventions and track the client's condition, the nurse should monitor the client's temperature, hydration status, and provide for early detection of complications.

A nurse is caring for a client who is postoperative following administration of general anesthesia. Vital Signs 0830: Temperature 36.9° C (98.5° F)Heart rate 134/minRespiratory rate 28/minBlood pressure 92/52 mm HgOxygen saturation 89% on room air Nurses' Notes 0830: Client is postoperative following an inguinal hernia repair.Apical pulse 134/min and irregularClient reports dyspnea.

Upon recognizing and analyzing the client cues of tachycardia, tachypnea, hypotension, and irregular heart rhythm, the nurse's priority hypothesis should be that this client is most likely experiencing malignant hyperthermia and that it is important to generate solutions and take actions that will correct dysrhythmias, provide oxygen to tissues, correct electrolyte imbalances, and reverse metabolic and respiratory acidosis. Therefore, the nurse should prepare to administer dantrolene and administer oxygen. The nurse should monitor the PCO2 level on the client's ABGs for hypercapnia and observe the client for muscle rigidity of the jaw and chest muscles.

a nurse is assessing a client who has a skeletal traction for a femur fracture. which of the following findings should the nurse identify as the priority?

Upper chest petechiae -The nurse should reposition the client or check the weights to relieve the client's muscle spasms. However, another finding is the priority. -The nurse should provide analgesia to relieve the client's moderate pain level. However, another finding is the priority. -The greatest risk to this client is organ damage from fat embolism syndrome, a life-threatening complication of fractures. In fat embolism syndrome, a fat embolus enters the blood stream and can obstruct blood vessels of a major organ, such as the lung, kidney, or brain. Manifestations include petechiae on the upper torso, dyspnea, hypoxia, headache, lethargy, and confusion. Therefore, the nurse should identify this as the priority finding. -The nurse should identify ecchymosis over the fractured area as an expected finding due to localized trauma and provide comfort measures. However, another finding is the priority.

A nurse is providing teaching for a client who has a fracture of the right fibula with a short-leg cast in place and a new prescription for crutches. The client is non-weight-bearing for 6 weeks. Which of the following instructions should the nurse include in the teaching?

Use a three-point gait. A three-point crutch gait allows the client to be mobile without bearing weight on the affected extremity.

A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures should the nurse follow to ensure proper client identification?

Verify the client and blood product information with another licensed nurse. The nurse should compare the blood product label against the medical record and the client's identification number with another nurse to ensure the correct blood product is administered to the correct client.

A nurse in a provider's office is caring for a client. Nurses' Notes Day 1, 0900: Client is 65-year-old who reports pain and burning on urination.Client states, "I am having trouble making it to the bathroom on time and I'm up throughout the night needing to urinate." Client alert and oriented to person, place, and time.Bilateral breath sounds clear. Respirations even and unlabored.S​3​ auscultated. Lower extremity edema +1. Radial and pedal pulses +2.Bowel sounds normoactive. Client reports no nausea or vomiting.Client has a history of type 2 diabetes mellitus, hypertension, and COPD.

When analyzing cues, the nurse should anticipate provider prescriptions to collect urine specimens for urinalysis and urine culture and to educate the client on new prescriptions for sulfamethoxazole/trimethoprim and phenazopyridine. The nurse should identify that the client is most likely experiencing a urinary tract infection (UTI). UTIs are diagnosed through urinalysis and urine culture. Clients experiencing a UTI should be prescribed an antibiotic and an analgesic for urinary pain relief and frequency.

Nurses' Notes Day 1, 0900: Client is a 65-year-old who reports pain and burning on urination.Client states, "I am having trouble making it to the bathroom on time and I'm up throughout the night needing to urinate." Client alert and oriented to person, place, and time.Bilateral breath sounds clear. Respirations even and unlabored.S3​ auscultated. Lower extremity edema +1. Radial and pedal pulses +2.Bowel sounds normoactive. Client reports no nausea or vomiting.Client has a history of type 2 diabetes mellitus, hypertension, and COPD.3 days later, 0900: Click to highlight the findings that indicate the client's urinary tract infection is improving. To deselect a finding, click on the finding again.

When evaluating outcomes, the nurse should identify that the client's urinary tract infection (UTI) is improving as evidenced by the client's urine specific gravity, pH, and WBC results. These findings are within the expected reference ranges and indicate that the medication has been effective in treating the UTI.

A nurse is caring for a 1-month-old infant. Nurses' Notes 1500: Infant admitted to the pediatric unit. Parent reports infant has been irritable and has vomited after each feeding within the last 3 days.Infant alert, not crying. S1 and S2 noted without murmurs. Lungs clear to auscultation anterior/posterior. Respirations even, unlabored. Abdomen firm. Bowel sounds hypoactive in all 4 quadrants. Small 1 x 1 cm2 mass palpated near umbilicus. Skin warm and dry, turgor with tenting. 1600: Called to room by parent. The client who gave birth attempted breastfeeding. Infant projectile vomited. No bile noted in vomit. Some blood-tinged vomitus noted. Instructed parent to keep child NPO. 1800: Infant crying. Soothed with pacifier.

When prioritizing hypotheses and using the urgent vs. nonurgent priority framework, the nurse should identify that the infant is at the greatest risk for developing dehydration due to a loss of gastric content from vomiting. An infant with pyloric stenosis presents with projectile vomiting after feeding, distended abdomen, and olive-shaped mass in the epigastrium.

A nurse is caring for a client who is pregnant in the acute care setting. Nurses' Notes 1400: Client reports a constant low dull backache and painless abdominal tightening for the past 3 hr. Denies any changes in vaginal discharge. External fetal monitor applied. 1430: Contraction pattern: contractions every 4 to 5 min, lasting 30 to 45 seconds, palpate mild in intensity. Fetal heart rate: 150/min to 155/min, moderate variability, adequate accelerations present, no decelerations noted. Provider in to see client. Specimen obtained for fetal fibronectin. 1800: Client sleepy. Difficult to arouse. Respirations slow and shallow. Contraction pattern: contractions every 10 min, lasting 30 to 45 seconds, palpate mild in intensity. Fetal heart rate: 140/min, moderate variability, no accelerations present, no decelerations noted. Vital Signs 1400: Temperature 37° C (98.6° F) Heart rate 72/min Respiratory rate 20/min Blood

When prioritizing hypotheses, the nurse should recognize that magnesium sulfate is a central nervous system depressant that can affect respirations, consciousness, and reflexes when toxic blood levels occur. Using the airway, breathing, circulation priority framework, the nurse should plan to first take action to support respirations, followed by action to increase the client's level of consciousness. The nurse should plan to discontinue the magnesium sulfate infusion and administer calcium gluconate as an antidote.

A nurse is assessing a newborn who is 3 days old. History and Physical Newborn was delivered at 37 weeks of gestation via cesarean section for fetal distress.Apgar scores: 8 at 1 min and 9 at 5 min.Birth weight: 2.9 kg (6 lb 6 oz)The client who gave birth plans to breastfeed. Flow Sheet Day 2 of Life, 0900: Temperature 36.7° C (98.1° F)Heart rate 140/minRespiratory rate 48/minWeight 2.7 kg (6 lb); 6% weight lossDay 3 of Life, 0800: Temperature 36.4° C (97.5° F)Heart rate 140/minRespiratory rate 48/min Weight 2.5 kg (5 lb 9 oz); 12% weight loss Nurses' Notes Day 3 of Life, 0800: Skin color consistent with newborn's genetic background. Respirations easy and unlabored. Abdomen soft with active bowel sounds. Mild tremors noted when awake. Anterior fontanel level and soft. Large ecchymotic caput succedaneum noted on posterior scalp. Small amount of bloody mucus discharge noted from vagina. Breastfeeding every 3 to 5 h

When recognizing cues, the nurse should identify that a temperature of 36.4° C (97.5° F) is below the expected reference range. Hypothermia can lead to the occurrence of hypoglycemia and respiratory distress. The newborn breastfeeding for short intervals, nipple discomfort, and a weight loss of greater than 10% of birth weight can indicate inadequate transfer of breastmilk, which can result in hypoglycemia. The presence of mild tremors can be a manifestation of hypoglycemia.

A nurse in a provider's office is caring for a client. Nurses' Notes Day 1, 0900: Client is 65-year-old who reports pain and burning on urination.Client states, "I am having trouble making it to the bathroom on time and I'm up throughout the night needing to urinate." Client alert and oriented to person, place, and time.Bilateral breath sounds clear. Respirations even and unlabored.S3 auscultated. Lower extremity edema +1. Radial and pedal pulses +2.Bowel sounds normoactive. Client reports no nausea or vomiting. Client has a history of type 2 diabetes mellitus, hypertension, and COPD.

When recognizing cues, the nurse should identify that the client's report of frequency, dysuria, and urgency are manifestations of a UTI and should be reported to the provider. These manifestations occur due to bacteria invading the urinary tract through the urethra.

A nurse is caring for a client who is postoperative following an appendectomy. Nurses' Notes 1800: Client alert and oriented to person, place, time, and situation.Skin warm and dry.Lungs clear on auscultationBowel sounds hypoactive in all four quadrants.Urine clear yellowIncisional dressing clean and dry.Client reports pain as 6 on a scale of 0 to 10. 1815: Morphine administered as prescribed. 2000: Client reports abdominal pain as 10 on a scale of 0 to 10.Client reports nausea, no vomiting.Incisional dressing is dry and intact with no breakthrough bleeding noted.Lung sounds are clear to auscultation.Hypoactive bowel sounds present in all four quadrants.

When recognizing cues, the nurse should identify that the findings of pain, nausea, heart rate, and oxygen saturation are unexpected findings for a client who is postoperative following an appendectomy. These findings should be reported to the provider.

A nurse in an outpatient mental health clinic is caring for a client. Nurses' Notes 3 months ago: Client recently admitted with new diagnosis of schizophrenia. Received inpatient treatment for 10 days and was discharged 1 week ago. Client is alert and oriented to person, place, time, and situation. Responds appropriately to questions. Client reports sleeping well and working at a local retail store.Today: Client presents for follow-up visit. Pressured speech noted. Appears to be listening to unseen others. Client is restless. Frequently getting out of chair. Appears tired and disheveled.

When recognizing cues, the nurse should identify that the findings of restlessness, auditory hallucinations, and pressured speech require immediate follow up. These findings are indications of psychosis. The nurse should notify the provider for additional evaluation and treatment.

A nurse is caring for an adolescent in the emergency department (ED). Laboratory Results Sodium 140 mEq/L (136 to 145 mEq/L) Potassium 3.6 mEq/L (3.5 to 5 mEq/L) Chloride 103 mEq/L (98 to 106 mEq/L) BUN 15 mg/dL (10 to 20 mg/dL) Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L) Total calcium 9.5 mg/dL (9 to 10.5 mg/dL) Phosphate 3.7 mg/dL (3 to 4.5 mg/dL) Glucose 80 mg/dL (74 to 106 mg/dL) Total protein 7 g/dL (6.4 to 8.3 g/dL) Albumin 4.5 g/dL (3.5 to 5 g/dL) WBC count 19,500/mm3 (5,000 to 10,000/mm​3) Aspartate aminotransferase (AST) 30 units/L (10 to 40 units/L) Alanine transaminase (ALT) 20 units/L (4 to 36 units/L) Diagnostic Results Cerebrospinal fluid examinationPressure: 35 cm H2​O (less than 20 cm H2O) Color: Cloudy (clear and colorless) Blood: None RBC: 0 (0 cells) WBC total: 120 cells/µL (0 to 10 cells/µL) Protein: 90 mg/dL (15 to 45 mg/dL) Glucose: 20 mg/dL (50 to 75 mg/dL) Medication Administration Record

When recognizing cues, the nurse should recognize that manifestations of bacterial meningitis can include fever, photophobia, nuchal rigidity, petechial rash, and impaired consciousness. The adolescent is experiencing these symptoms. Encephalitis is characterized by fever, nuchal rigidity, and altered mental status. Reye syndrome is characterized primarily by altered mental status and impaired hepatic function.

The client returns to the provider's office 3 days later. Nurses' Notes Day 1, 0900: Client is 65-year-old who reports pain and burning on urination.Client states, "I am having trouble making it to the bathroom on time and I'm up throughout the night needing to urinate." Client alert and oriented x 3.Bilateral breath sounds clear. Respirations even and unlabored.S​3 auscultated. Lower extremity edema +1. Radial and pedal pulses +2.Bowel sounds normoactive. Client reports no nausea or vomiting.Client has a history of type 2 diabetes mellitus, hypertension, and COPD. 3 days later, 0900: Client returns to office due to orange-colored urine and diarrhea.Client reports drinking a minimum of 3 L of fluids daily as instructed and states, "I'm still going to the bathroom a lot, and I noticed that I am bruising more easily." Which of the following assessment findings should the nurse report to the provider as unexpected?

When taking action, the nurse should identify that the client's urine color, voiding pattern, oxygen saturation, and blood pressure are expected findings and do not need to be reported to the provider. The client's report of orange urine is an expected finding due to the prescribed medication phenazopyridine, which can cause reddish-orange discoloration of urine. The client's voiding pattern is an expected finding due to increased fluid intake of 3 L daily. The client's oxygen saturation is an expected finding due to the client's history of COPD. The client's blood pressure is an expected finding due to the client's history of hypertension. The nurse should identify that the client's temperature, skin, and bowel elimination are unexpected findings and should be reported to the provider. The client's temperature is above the expected reference range, which can be an indication of Clostridium difficile. The client's diarrhea can also be an indication of C. difficile. The client's unexpected bruising can be an indication of Stevens-Johnson syndrome. C. difficile and Stevens-Johnson syndrome are potential side effects of trimethoprim/sulfamethoxazole.

A nurse is caring for a client following a laparoscopic cholecystectomy. Nurses' Notes 1030: 33-year-old client is 1 hr postoperative following a laparoscopic cholecystectomy. Alert and oriented to person, place, and time. Skin warm and dry. Lungs clear auscultated throughout all lung fields. Normal sinus rhythm. Client denies nausea and vomiting, bowel sounds hypoactive in all four quadrants. Peripheral pulses +2 bilaterally. Incision dressing clean and dry, incision intact upon inspection, no redness, swelling, or drainage noted.

When taking actions for a client who is postoperative following a laparoscopic cholecystectomy, the nurse should anticipate prescriptions for the client to apply heat for abdominal pain as needed, to encourage deep breathing, and to change the dressing when soiled. The client can use heat for abdominal pain related to carbon dioxide retention. During the procedure, carbon dioxide is inflated into the abdominal cavity for visualization for the provider. The client's dressing should be changed when soiled as needed. The dressing should be clean, dry, and intact to prevent infection. The nurse should identify that medication for nausea should be provided as needed and is contraindicated for scheduled administration.

a charge nurse is observing a newly licensed nurse performing a physical assessment on a client. which of the following actions by the nurse indicates that the charge should intervene?

the new nurse writes detailed notes while performing the HTTA The newly licensed nurse should record brief notes during the assessment to avoid delays and write more detailed notes after completing the assessment.

A charge nurse is providing an educational session about infection control for a group of staff nurses. Which of the following statements by one of the staff nurses indicates an understanding of isolation precautions?

"A client who requires airborne precautions should be placed in a negative-pressure airflow room." Airborne precautions require a negative-pressure airflow room that has at least six to 12 air exchanges each hour using a HEPA filtration system.

A nurse is admitting a client to the mental health unit after an attempted suicide. The client states, "My family does not care whether I live or die." Which of the following responses should the nurse make?

"How does this make you feel?"

A nurse is providing teaching about advance directives to a middle adult client. Which of the following client responses indicates an understanding of the teaching?

"I can designate my partner as my health care surrogate." This statement indicates that the client recognizes that designating a health care surrogate is part of advance directives.

A clinic nurse is caring for a client who is in the first trimester of pregnancy. The client reports using acupressure bands on both wrists. Which of the following statements by the client indicates that this therapy is having the desired effect?

"I have not vomited as much recently." Using an acupressure band on the wrists is a type of complementary and alternative therapy that applies pressure to a specific part of the body and can be used to alleviate nausea and vomiting.

A nurse is providing discharge instructions to a client who has a new prescription for amitriptyline to treat depression. The nurse should identify that which of the following client statements indicates an understanding of the teaching?

"I should watch for common reactions like dry mouth and constipation." The nurse should reinforce that increasing dietary fiber, fluid intake, and chewing sugar-free gum can alleviate the anticholinergic effects of dry mouth and constipation.

A nurse is conducting group therapy with clients who have breast cancer. The nurse should recognize which of the following statements by a client as an example of altruism?

"I told my doctor that I would like to start a support group for other people who are sick in my community." This statement indicates that the client is demonstrating altruism by reaching out and helping others.

A nurse is providing information to a client immediately before their scheduled Romberg test. Which of the following statements should the nurse make?

"I will be checking you once with your eyes open and once with them closed." The nurse should inform the client that the Romberg test will be performed once with eyes open and once with eyes closed. A Romberg test is performed to assess balance and motor function.

Nurse preparing to admin diazepam 0.3 mg/kg IV bolus to a toddler who weighs 10 kg (22lb) and is experiencing grand mal seizure. avail is diazepam solution for injection 5mg/mL. how many mL should nurse administer?

0.6 mL Determine whether the amount to administer makes sense. If there are 5 mg/mL, the prescription reads 0.3 mg/kg, and the toddler weighs 22 lb, it makes sense to administer 0.6 mL. The nurse should administer diazepam 0.6 mL IV bolus.

A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia? A. Irritability B. Increased urination C. Vomiting D. Facial warmth

A The nurse should instruct the client to monitor for irritability, which can indicate decreased blood glucose levels.

A nurse is administering 1 unit of packed RBCs to a client. The client becomes anxious and reports shortness of breath and urticaria 15 min after initiation of the transfusion. Which of the following actions should the nurse take? A. Prepare to administer epinephrine to the client. B. Decrease the rate of the client's transfusion. C. Obtain a culture of the client's blood. D. Anticipate administering diuretics to the client.

A The nurse should recognize that the client is experiencing an anaphylactic reaction to the blood transfusion. Therefore, the nurse should prepare to administer epinephrine to the client to alleviate manifestations of anaphylaxis.

a nurse is caring for a newborn immediately after delivery. which of the following interventions should the nurse implement to prevent heat loss by conduction? A. dry immediately after birth B. maintain ambient room temp of 24 degrees C. use protective cover on the scale when weighing D. place bassinet away from outside windows

C Heat loss by conduction is a loss of heat between the newborn's skin and the cooler surfaces beneath it. Using a protective cover prevents contact with the scale, which prevents the loss of heat through conduction.

A nurse is caring for a client on a medical-surgical unit. Vital Signs 0700: Temperature 37.6° C (99.7° F) Heart rate 100/min Respiratory rate 22/min Blood pressure 115/70 mm Hg Oxygen saturation 98% on room air Nurses' Notes 1100: Client alert and oriented to person, place, and time. Client had episode of diarrhea, provided perineal care. Noted 2 cm x 2 cm (0.8 in x 0.8 in) painful edematous area on sacrum. Client repositioned every 4 hr.

Click to highlight the findings that require follow up. To deselect a finding, click on the finding again. When recognizing cues, the nurse should determine that the client's painful edematous area on their sacrum and that the client has only been repositioned every 4 hr requires follow up. The client has manifestations of a pressure injury that need to be addressed. The client should be repositioned at least every 2 hr to prevent worsening of the pressure injury and to relieve pressure from the sacral area.

A nurse is assessing a client who has been taking lithium carbonate for the past month to treat bipolar disorder. Which of the following assessment findings should the nurse identify as the priority?

Confusion When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is confusion because it is an early manifestation of lithium toxicity. The nurse should monitor the client for additional indications of lithium toxicity, including coarse hand tremors, incoordination, ECG changes, and sedation.

A nurse in an emergency department is assessing a school-age child who was brought in by their parents and has scald burns to both hands and wrists. The nurse suspects physical abuse. Which of the following actions should the nurse take?

Contact Child Protective Services. The nurse has a legal responsibility to report suspected physical abuse to Child Protective Services.

A nurse is teaching about adverse effects with a client who is starting to take captopril. Which of the following findings should the nurse identify as an adverse effect of the medication to report to the provider?

Cough The client can develop a cough due to a buildup of bradykinin in the lungs. The client should report this finding to the provider.

A client is receiving IV fluids at 150 mL/hr. Which of the following findings indicates that the client is experiencing fluid overload?

Dyspnea The nurse should recognize that dyspnea indicates the client could be experiencing fluid overload. Fluid overload can lead to the backup of fluid in the pulmonary system, resulting in shortness of breath.

A nurse is preparing to transfer a client who has had a stroke to a rehabilitation facility. The client's family tells the nurse they are concerned about the level of care the client will receive. Which of the following actions should the nurse take?

Facilitate an interdisciplinary conference at the new facility for the family.

A nurse is performing an admission assessment on a client who had a recent positive pregnancy test. The first day of their last menstrual period (LMP) was May 8. According to Naegele's rule, which of the following dates should the nurse document as the client's estimated date of birth (EDB)?

February 15 Using Naegele's rule, the nurse should add 7 days to the first day of the client's LMP (8 + 7 = 15) and then subtract 3 months. Therefore, the nurse should document the client's EDB as February 15th.

A nurse at an urgent care clinic is assessing a client who reports impaired vision in one eye. Which of the following reports by the client should indicate to the nurse that the client has a detached retina?

Floating dark spots

A nurse is administering medications to a client who has a percutaneous gastrostomy tube for enteral feedings. Which of the following actions should the nurse take to prevent clogging of the tube?

Flush the client's gastrostomy tube with 30 mL of water before administering the medication. The nurse should flush the gastrotomy tube with at least 30 mL of water before and after medication administration to clear the tube of any residuals and to ensure patency.

A nurse is caring for a client who is in the manic phase of bipolar disorder. Which of the following manifestations should the nurse expect?

Grandiose delusions Clients who are in the manic phase of bipolar disorder typically exhibit behaviors that appear to be euphoric. Clients can also have abrupt mood changes, expansiveness, unlimited energy, poor impulse control, and grandiose delusions.

A nurse is assessing a client who has obstructive sleep apnea. For which of the following complications should the nurse monitor?

Hypertension The nurse should assess the client for hypertension, a complication of obstructive sleep apnea from hypoxia. Other complications include heart failure and cardiac dysrhythmias.

the nurse is providing edu to the parent of a school age child with asthma. which of the following statements by the parent indicates an understanding of the teaching?

I will make sure my child receives a yearly influenza immunization Children who have asthma should be immunized and protected from infections. Therefore, the nurse should educate the parent to ensure the child receives a yearly influenza immunization.

A nurse on a mental health unit is conducting a mental status examination (MSE) on a newly admitted client. Which of the following components of the MSE is the priority for the nurse to assess?

Ideas of self-harm The greatest risk to this client is injury from ideas of self-harm. Therefore, the priority assessment the nurse should make is to determine whether the client has had suicidal or homicidal ideas.

A nurse is caring for a client who has generalized anxiety disorder and is to begin taking alprazolam. Which of the following actions should the nurse take?

Initiate fall precautions for the client. The nurse should initiate fall precautions for a client who has a new prescription for alprazolam because common adverse effects associated with this medication are orthostatic hypotension, dizziness, confusion, and lethargy.

A nurse is assessing a school-age child who has bacterial meningitis. Which of the following findings should the nurse expect?

Nuchal rigidity

A nurse is preparing to assist with a thoracentesis for a client who has pleurisy. The nurse should plan to perform which of the following actions?

Instruct the client to avoid coughing during the procedure. It is important for the nurse to remind the client to avoid coughing and to lie still during a thoracentesis to avoid puncturing the pleura.

A nurse is caring for a client who has a deep vein thrombosis. Which of the following actions should the nurse take?

Instruct the client to elevate the affected extremity when sitting. The nurse should instruct the client to elevate the affected extremity when in the bed or chair.

A nurse is preparing a client for a paracentesis. Which of the following actions should the nurse take?

Instruct the client to void. The nurse should instruct the client to void prior to the procedure because an empty bladder decreases the risk of a bladder puncture and minimizes the client's discomfort during the procedure.

A nurse is providing dietary teaching to the parents of a 6-month-old infant. Which of the following instructions should the nurse include?

Introduce new foods one at a time over 3 to 5 days. The parents should introduce new foods one at a time over 3 to 5 days to identify potential food allergies.

A nurse is caring for a client who requires physical therapy following discharge. Which of the following actions should the nurse take?

Involve the client in selection of a physical therapy provider. The nurse should involve the client in the referral process, including selection of the physical therapist and the location.

A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings should indicate to the nurse that the client is having a hemolytic transfusion reaction?

Low back pain

A nurse is caring for a client who has had nausea and vomiting for the past 2 days. The nurse should identify which of the following findings as an indication the client is experiencing fluid volume deficit?

Orthostatic hypotension Clients who have a fluid volume deficit can experience orthostatic hypotension, which is a result of the body's inability to maintain adequate blood pressure following position changes.

A community health nurse is assisting with the development of a disaster management plan. The nurse should include which of the following nursing responsibilities in the disaster response stage of the plan?

Performing a rapid needs assessment Disaster management includes prevention, preparedness, response, and recovery stages. The nurse should perform a rapid needs assessment during the response phase of the disaster cycle. A rapid needs assessment allows the nurse to identify the severity of the incident, the health needs of the community, and the priority actions needed during the response stage.

A nurse is caring for a client who is at 37 weeks of gestation and is experiencing abruptio placentae. Which of the following findings should the nurse expect?

Persistent uterine contractions The nurse should expect a client who has abruptio placentae to experience persistent uterine contractions, board-like abdomen, and dark red vaginal bleeding.

A nurse is assessing a client who has pulmonary edema. Which of the following findings should the nurse expect?

Pink, frothy sputum

A nurse is caring for a client who vomits on a reusable BP cuff. Which of the following actions should the nurse take?

Place the BP cuff in a labeled bag to send it for decontamination. The nurse should place the BP cuff in a labeled bag before removing it from the client's room and sending it to the proper facility location for decontamination.

A nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the client's family to obtain consent. Which of the following actions should the nurse take?

Proceed with provision of medical care. When a client is unable to give informed consent in an emergency, health care personnel can proceed with necessary life-saving care because the law considers this implied consent.

A nurse manager is planning to make changes to the current scheduling system on the unit. To facilitate the staff's acceptance of this change, which of the following actions should the nurse manager take first?

Provide information about scheduling issues to the staff. The first stage of the change process is the unfreezing stage, when the nurse should inform the staff about the current staffing issues. This can increase their understanding of why changes are necessary.

A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client?

Radial vein of the inner arm The nurse should select the radial vein of the inner arm when initiating IV access for an older adult client because this site will have adequate subcutaneous tissue.

A nurse working in a long-term care facility is assessing an adult client. Which of the following findings places the client at risk for the development of a pressure injury?

Recent weight loss Weight loss can increase the client's risk for developing a pressure injury. Inadequate nutrition will cause decreased nutrients for the skin and tissues and an increased chance for shearing against bony prominences.

A nurse is assessing a client after administering epinephrine for an anaphylactic reaction. Which of the following findings should the nurse identify as an adverse effect of this medication?

Report of chest pain The nurse should identify that a report of chest pain by the client can indicate an adverse effect of the medication. Epinephrine increases cardiac workload and oxygen demand, which can result in angina.

A nurse is caring for a school-age child who has dehydration and is receiving an oral rehydration solution. Which of the following laboratory results indicates that the treatment regimen is effective?

Serum sodium 138 mEq/L A serum sodium level of 138 mEq/L is within the expected reference range of 136 mEq/L to 145 mEq/L and is an indication that the child is responding to the oral rehydration solution.

A nurse is preparing a sterile field in order to insert an indwelling urinary catheter for a male client. Which of the following techniques should the nurse use to maintain surgical aseptic technique?

Set the catheter tray on the overbed table at waist height.

A nurse is caring for a client who states, "My boss accused me of stealing yesterday. I was so angry I went to the gym and worked out." The nurse should recognize the client is demonstrating which of the following defense mechanisms?

Sublimation The client is exhibiting behaviors consistent with sublimation, which is displayed when a client substitutes socially unacceptable behavior for acceptable behavior.

A nurse in an acute mental health facility is planning care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the client's plan of care?

Supervise the client during and after eating. The nurse should monitor the client during and for 1 hr after meals to prevent the client from hiding food or purging.

A school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. Upon arrival at the playground, which of the following actions should the nurse take first?

Survey the scene for potential hazards to staff and children. The first action the nurse should take when using the nursing process is to assess the situation. By surveying the scene, the nurse can identify potential hazards to staff and children. These findings allow the nurse and staff to enter the scene and safely provide care to injured children and help decrease the risk for further injury.

A nurse is providing teaching to a client who has a prescription for levothyroxine 25 mcg PO daily. Which of the following instructions should the nurse include in the teaching?

Take the medication on an empty stomach 30 min before breakfast.

A nurse on a medical-surgical unit is caring for a client prior to a surgical procedure. Which of the following findings should indicate to the nurse that the client has the ability to sign the informed consent?

The client is able to accurately describe the upcoming procedure. The ability of the client to accurately describe the upcoming procedure indicates that the provider adequately informed the client and that the client is able to sign the informed consent form.

A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse plan to take?

Use the ventrogluteal site. The nurse should use the ventrogluteal site because it has a thick area of muscle and contains no large nerves or blood vessels.

A nurse is caring for a client in the emergency department (ED). Nurses' Notes 0600: Client admitted to the ED with fatigue, shortness of breath, and weakness for the last 2 days. Client states that they have a history of sickle cell disease (SCD). Client is alert and orientated to person, place, and time. Restless. Client rates generalized pain as a 9 on a scale of 0 to 10. Vital signs taken and blood drawn for laboratory tests. Oxygen 2 L via nasal cannula applied. Awaiting prescription for pain management. 0615: Client still rates pain as a 9 on a scale of 0 to 10. Hydromorphone 4 mg IV administered.

When taking actions, the nurse should administer IV fluids, use humidification with oxygen therapy, and assess the client's mouth every 8 hr and peripheral circulation hourly. Hydration is a priority when caring for a client in sickle cell crisis because it decreases the rate of cell sickling and can reduce pain. Hypotonic fluids are typically infused at 250 mL/hr for 4 hr. Oxygen administered without humidification can cause drying of the mucous membranes, especially in clients who are already fluid-depleted. Placing humidification on the oxygen therapy promotes comfort and reduces the risk of sores and lesions of the mucous membranes. The nurse should assess the client's peripheral circulation because of the risk of venous occlusion caused by the sickling and clumping of the red blood cells and assess the client's mouth at least every 8 hr for the presence of sores or lesions and any other signs of infection.

A nurse is providing teaching to a parent of a child who has a permanent tracheostomy tube. Identify the sequence of steps the parent should follow to perform tracheostomy care. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

When teaching the parent to provide tracheostomy care, the nurse should instruct the parent to first 1. remove the inner cannula. 2. remove the soiled dressing. 3. clean the stoma with 0.9% sodium chloride irrigation. 4. change the tracheostomy collar.

A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm3 (2500 to 8000/mm3). Which of the following interventions should the nurse include in the plan?

Withhold administering the varicella vaccine to the child. A child who has severe immunodeficiency should not receive a live vaccine due to the risk of developing the disease. Inactivated vaccines can be administered to children who are immunosuppressed.

A nurse on an antepartum unit is caring for a client who is at 33 weeks of gestation. Diagnostic Results WBC count 9,800/mm3 (5,000 to 10,000/mm3)Hgb 13 g/dL (greater than 11 g/dL)Hct 41% (greater than 33%)Platelet count 170,000/mm3 (150,000 to 400,000/mm3)BUN 20 mg/dL (10 to 20 mg/dL)Lactate dehydrogenase (LDH) 80 units/L (100 to 190 units/L)Aspartate aminotransferase (AST) 18 units/L (0 to 35 units/L) Alanine aminotransferase (ALT) 19 units/L (4 to 36 units/L)Uric acid (serum) 5.4 mg/dL (2.7 to 7.3 mg/dL)Kleihauer-Betke (fetal hemoglobin test) 3% (less than 1%)Blood type: ARh: positiveUrine reagent stripGlucose: nonepH: 6Specific gravity: 1.020Ketones: noneNitrates: noneLeukocyte esterase: negativeProtein: negativeNitrites: none

actions: avoid cervical exam & insert large bore IV catheter experiencing: abruptio placentae parameters to monitor: BP & Platelet count The nurse should avoid cervical examination and insert a large-bore IV catheter because the client is most likely experiencing abruptio placentae indicated by the sudden onset of abdominal pain, contractions, and dark red vaginal bleeding. Cervical examination can cause further damage to the placenta and increase bleeding. The nurse should immediately establish IV access with a large-bore catheter to administer IV fluids and blood products if bleeding increases or if manifestations of fetal distress occur. The nurse should monitor the client's blood pressure and platelet count because of the risk of significant blood loss due to the abruption. Hemorrhage might not be visible as vaginal bleeding if it is concealed between the placenta and uterine wall. Therefore, manifestations of hypovolemic shock (decreasing blood pressure, increasing heart rate) can provide indications that internal placental bleeding is worsening. Abruptio placentae can also lead to alterations in coagulation, such as disseminated intravascular coagulation, further increasing the client's risk for hemorrhage. Therefore, the nurse should monitor the client's platelet count to identify if the client is at an increased risk for bleeding.

A nurse is planning teaching about allowable foods for a client who has a history of uric acid-based urinary calculi formation. Which of the following foods should the nurse include in the teaching?

oranges A client who is prone to uric acid calculi formation can eat citrus fruits.

A nurse is caring for a client who is 1 day postoperative following a total thyroidectomy. Laboratory Results 0700: Sodium 143 mEq/L (136 to 145 mEq/L) Potassium 3.5 mEq/L (3.5 to 5 mEq/L) Chloride 104 mEq/L (98 to 106 mEq/L ) BUN 15 mg/dl (10 to 20 mg/dl) Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L ) Total calcium 8 mg/dL (9 to 10.5 mg/dL) Phosphate 4.6 mg/dL (3 to 4.5 mg/dL) Glucose 95 mg/dL (74 to 106 mg/dL) WBC 9,500/mm3 (5,000 to 10,000/mm3) Nurses' Notes 0700: Client alert and oriented to person, place, and time. Respirations even and unlabored with no adventitious sounds. Bowel sounds active in all 4 quadrants. Surgical dressing dry, slight edema at incision site noted. Client rates dull pain in neck of 2 on a 0 to 10 scale. Declines pain medication. 1100: Client alert and oriented to person, place, and time. Respirations even and unlabored with no adventitious sounds. Bowel sounds active in all 4 quadrant

the client is at highest risk for developing hypocalcemia as evidenced by client's report of muscle spasms, numbness around lips, and dec calcium level. Hypocalcemia is more likely to occur in clients who have experienced a thyroidectomy, due to accidental damage to the parathyroid. Numbness around the lips is a clinical manifestation specific to hypocalcemia. Hypocalcemia presents as muscle spasms and can lead to cardiac dysrhythmias. Hypocalcemia is the highest priority, as it requires immediate treatment with calcium gluconate to avoid dysrhythmias and other complications.

A nurse on the medical-surgical unit is caring for a client who was admitted from the emergency department (ED). Vital Signs 1400: Temperature 38° C (100.4° F) Heart rate 110/min Respiratory rate 24/min Blood pressure 96/58 mm Hg Oxygen saturation 96% on room air 1500: Temperature 37.2° C (98.9° F) Heart rate 96/min Respiratory rate 20/min Blood pressure 100/70 mm Hg Oxygen saturation 97% on room air Nurses' Notes 1500: Client admitted from the ED for dehydration. Client alert and oriented to person, place, and time. Client reports they are feeling "weak." IV dextrose 5% in water (D5​​W) infusing at 100 mL/hr. Laboratory Results 1400: Calcium 10.2 mg/dL (9 to 10.5 mg/dL) Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L) Potassium 4.7 mEq/L (3.5 to 5 mEq/L) Sodium 150 mEq/L (136 to 145 mEq/L) 1700: Calcium 9.5 mg/dL (9 to 10.5 mg/dL) Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L) Potassium 4.1 mEq/L (3.5 to 5 mEq/L) Sodium 16

the client is at risk for developing confusion due to sodium level Upon analyzing cues, the nurse should identify that the client is at risk for confusion due to a sodium level that is greater than the expected reference range. Hypernatremia places the client at risk for a decreased level of consciousness, falls, and seizure activity. Therefore, the nurse should monitor the client's level of consciousness and place the client on fall and seizure precautions.