NGN
A nurse is an ER caring for a client Diagnostic results: 1215: ECG Normal sinus rhythm 1250: Xray right arm: FX of right radius The nurse is preparing to speak to the facility Social Worker about the clients condition Select the 5 findings the nurse should plan to include in report
Client report of lack of food in home Numerous bruises in various stages of healing Clients avoidance of eye contact Clients report of lack of access to bank accounts Clients report of weight loss
A nurse is an ER caring for a client Nurses notes: Client is an 82 year old male who presents with his adult child for evaluation of right arm pain after a fall, Noted to have several superficial abrasions on right forearm and elbow, also has numerous bruises in various stages of healing on arms and upper chest. 1210: Client noted to keep head down and makes limited eye contact. speaks very softly and looks at adult child before answering............... For each assessment finding, click to specify if the finding is an indication of physical maltreatment, neglect or financial maltreatment.
Client reports having little food in house: Neglect, financial Client has bruises various stages: Physical maltreatment Client wears dirty clothes: Neglect Client has no access to bank acct: Financial maltreatment:
A nurse is caring for a client who has been admitted in the antepartum unit Vital signs: Day 1 0900: Admission: temp 101.1 F HR: 92 Respiratory rate: 18 BP: 13078 Pre-pregnancy: BMI 27.6 Current BMI: 29.9 Complete the following ( it was no visible)
Previous preterm birth preterm labor
A nurse is caring for a client Nurses notes: 0900 Client reports a 3 month of history of intermittent diarrhea and abdominal pain. Reports unintentional weight loss of 5.5kg (12lbs) in 3 months. 0930: Stool sample obtained for fecal occult blood test. Fatty appearance and foul odor noted For each assessment finding, click to specify if the finding is consistent with ulcerative colitis, diverticulitis, or Crohns disease
Ulcerative colitis: Fever, weight loss, diarrhea Diverticulitis: Fever, anemia, diarrhea Crohn's disease: Fever, steatorrhea, anemia, weight loss, diarrhea
A nurse is caring for a client who has been admitted to the antepartum unit: 0900: client reports lower back pain and pinkish vaginal discharge, Uterine contractions every 8 minutes, palate strong, duration 30 seconds FHR 145, Cervical exam indicates 2cm 50% effaced, 0 station............... The client is at risk for developing which of the following 2 complications?
sepsis PROM
A nurse in an emergency department is caring for a client H&P 0400: 57 year old male client presents to the severe abdominal and epigastric pain that began about 12 hr ago. Pain 7/10, reports pain worsens after eating and radiates into his back. Nauseous and has had several episodes of vomiting.......Consumed 3 to 4 alcohol drinks per day...... The nurse is preparing to discharge the client. Which of the following statement by the client indicate an understanding of the discharge teaching?
" I will eat small frequent meals." " I should expect my bowel movements to be pale in color." " I will eat fish for dinner at least twice per week."
A nurse in an emergency department is caring for a client H&P 0400: 57 year old male client presents to the severe abdominal and epigastric pain that began about 12 hr ago. Pain 7/10, reports pain worsens after eating and radiates into his back. Nauseous and has had several episodes of vomiting.......Consumed 3 to 4 alcohol drinks per day...... The nurse is providing teaching to the client about self-care. Select 3 statements the nurse should include in the teaching
"Notify your provider if you experience vomiting or diarrhea" " You should eat foods that are low in fat." " You should eat foods high in protein."
A nurse caring for a client admitted to the hospital. 0900: The client reports experiencing a loss of appetite and SOB within the last month or so. Experiencing weakness, abdominal pain, severe itching and mood changes. Has alcohol use disorder for the past 10 years and sometimes drinks uncontrollably ............................ Select the 5 actions the nurse should take
1.) Provide frequent rest periods for the client 2.) Restrict the clients sodium intake 3.) Advise the client to avoid the use of soap and alcohol based lotions 4.) Instruct the client to avoid blowing their nose forcefully 5.) Assess the clients level of orientation
Q174 A nurse assisting with the care of a client Day1 Admitting to medical surgery unit following exploratory laparotomy for a ruptured appendix. Alert and oriented x3, Bilateral breath sounds clear and present throughout, bilateral pedal pulses 2+, Abdominal dressing with small serosanguineous drainage.............Reports feeling something popped at the ab incision site after coughing............. Select the 3 findings that require immediate f/u
1.) Respiratory rate 2.) abdominal dressing 3.) heart rate
Q169: The nurse is continuing to assist the care of the client 0900: 0930: client is at 31 weeks of gestation and presents with a severe headache unrelieved by acetaminophen. Urinary frequency and decreased fetal movement. Constant throbbing HA and pain 6/10. Denies visual disturbance, 3+ pitting edema bilateral lower extremities, 3 fetal movements with 30 mins, external fetal monitor FHR 140min, no uterine contractions Put the words from the choices in the blank spaces: The complications that the client is at greatest risk for developing are: _________________and_________________
1.) Seizures 2.) Placental abruption
Q171 Post op day 3 0900: Client reports pain at sx incision site 5/10, client reports bladder fullness, perineal dressing intact with minimal serosanguineous drainage, client transferring out of bed to chair independently, extremities cool and dry with 2+ peripheral pulses 1300: client reports abdominal cramping and small, hard, painful bowel movement after lunch........... Select 2 actions the nurse should prepare to take for the client
1.) administer an enema 2.) Encourage oral fluid intake
A nurse in an emergency department is caring for a client H&P 0400: 57 year old male client presents to the severe abdominal and epigastric pain that began about 12 hr ago. Pain 7/10, reports pain worsens after eating and radiates into his back. Nauseous and has had several episodes of vomiting.......Consumed 3 to 4 alcohol drinks per day...... The nurse is preparing to notify the provider about the client's current condition, for each potential provider prescriptions click to specify if the prescription is anticipated or contraindicated for the client
Administer famotidine 20mg via intermittent IV infusion twice daily: anticipated Insert an indwelling urinary catheter: contraindicated Administer lactated Ringers 1L via IV bolus: anticipated Insert a nasogastric tube and maintain low intermittent suction: anticipated
The nurse reinforcing teaching for the client and their family about potential adverse effects of the clients prescribed medication For each potential adverse effect, click to specify if the effect is consistent with agranulocytosis, neuroleptic malignant syndrome, or serotonin syndrome
Agranulocytosis: High fever, sore throat, BP changes, Tachycardia Neuroleptic malignant syndrome: Disorientation, BP changes, tachycardia Serotonin syndrome: High fever, B changes, tachycardia
Q 160: Report an issue, a nurse is assisting with the care of a client: H&P: 6 weeks ago: client presents to an outpatient psych office for evaluation of depression. symptoms started 2 months ago. Client reports depressed mood, lack of pleasure in activities that they enjoyed, hypersomnia, and fatigue. The nurse is reinforcing teaching for the client and their family about potential adverse effects of the clients prescribe medications. For each potential adverse effect, click to specify if the effect is consistent with agranulocytosis, neuroleptic malignant syndrome, or serotonin syndrome
Agranulocytosis: sore throat, high fever Neuroleptic malignant syndrome: BP changes, high fever Serotonin syndrome: Disorientation, BP changes, tachycardia, high fever
Q161: Report an issue: The nurse is assisting in the care of the client who is in the behavioral health unit. Nurses notes: 2015: 2030: client appears dishevels with matted hair and stained clothing. Client states I have to get out of here, i hear helicopters. They are coming to get me, My name is Jamie and you are the devil." Client appears to be responding to internal stimuli but is less outwardly agitated Put the words from the choices below to fill in each blank in the following The nurse should plan to _______ and ___________
Ask the client what they are hearing Reduce excess stimulation around the client
Q 163: A nurse is assisting with the care of a client who is pregnant Nurse note: 0900 Client is at 31 gestation and presents with severe headache unrelieved by acetaminophen. Reports urinary frequency and decreased fetal movement, client is gravida 3, para 2 with one preterm birth Select 4 findings that the nurse should identify as a potential prenatal condition
Blood presssure Fetal activity Headache Urine protein
A nurse is assisting with the care of a client in an outpatient clinic. 0800: Client awake alert and oriented. Nurse notes presence of exophthalmos and goiter. Peripheral pules resent, no peripheral edema noted, breath sounds equal and clear. 1030: Client is somnolent, difficult to arouse and displaying fine tremor.................... Click to highlight the findings that indicate an acute problem that warrants immediate intervention for each body system
Cardiovascular: 1+ bilateral lower extremity edema HEENT: Exophthalmos, goiter Neuro: Fine tremor, somnolent VS: BP 178/80, HR: 132 Resp: 20 Temp 101.3
Q 167: Nurse assisting care of a client 1500: client transferred from postanesthesia care unite following a left lung lobectomy. Client alert and oriented to person, place.....Pain 3/10. Water seal chest tube drainage system has 100 ml sanguineous drainage. Right lung sounds clear. Left lung sounds diminished For each potential nursing action: click to specify if the potential action is indicated or contraindicated for the client who has a chest tube
Clamp chest tube when client ambulates: contraindicated Report burning pain in chest to provider: indicated Reinforce dressing around the tube as needed if it loosens: indicated Strip the tubing twice daily to ensure patency: Contraindicated Maintain chest tube below the chest: anticipated
A nurse in an emergency department is caring for a client H&P 0400: 57 year old male client presents to the severe abdominal and epigastric pain that began about 12 hr ago. Pain 7/10, reports pain worsens after eating and radiates into his back. Nauseous and has had several episodes of vomiting.......Consumed 3 to 4 alcohol drinks per day...... Click the highlight findings that require follow-up
Client presents for evaluation of severe pain in upper abdomen that radiates into his back States pain began approximately 12 hr ago and is worse when he is supine or after he eats Sclera noted to be yellow Client guards abdomen and grimaces during palpation
The nurse reviews the entries in the medical record Provider Prescriptions: 0.9 sodium chloride 500ml bolus than 100ml/hr. Type and cross match for 2 units of packed RBCs, Repeat WBC, hemoglobin, hematocrit STAT, Delay endoscopy, 2L/min via nasal cannula............. The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client
Document the blood product transfusion in the clients medical record: Indicated Stay with the client for the first 15 min of the transfusion: Indicated Titrate the rate of infusion to maintain the clients blood pressure at least 90/60: Not indicated Obtain the first unit of packed RBCs from the blood bank: Indicated Start the IV bolus lactated ringers solution: Not indicated
Q165: A nurse is assisting with the care of a client who has pneumonia Admission assessment: 0100 Pedal pulse 2+ clients skin warm to touch. crackles auscultated in lower lung lobes bilaterally, mucous membranes show color expected for clients skin tone and dry, client reports productive cough with yellow sputum. allergy to PCN For each potential nursing action, click to specify if the potential action is anticipated or contraindicated for the client
Elevate extremity: Anticipated Send the catheter tip for culture: Contraindicated Assist in inserting a new IV catheter in a site distal to infiltration site: contraindicated Suggest irrigating the IV catheter: Contraindicated Apply a cool compress to the extremity: Anticipate Administer phytonadione: Contraindicated
Q173 A nurse is assisting with the care of a client on an orthopedic unit Progress report: Day 1 Admission: 0800 Client hospitalized following a motor vehicle crash. open fracture to right femur. Reduction of fx and internal fixation device used to stabilize, splint applied Fill in the following: The client is at risk for developing___________
Fat embolism syndrome
Q170: The nurse is continuing to assist with the care of the client 0900: 0930: client is at 31 weeks of gestation and presents with a severe headache unrelieved by acetaminophen. Urinary frequency and decreased fetal movement. Constant throbbing HA and pain 6/10. Denies visual disturbance, 3+ pitting edema bilateral lower extremities, 3 fetal movements with 30 mins, external fetal monitor FHR 140min, no uterine contractions Which of the following interventions should the nurse include?
Give antihypertensive medication Administer betamethasone Provide low stimulation environment Maintain bedrest Monitor intake and output every hour Obtain a 24 hr urine specimen
A nurse is caring for a client who has been admitted to the antepartum unit. Vital signs: Day 1 0900: Admission: temp 101.1 F HR: 92 Respiratory rate: 18 BP: 130/78 Pre-pregnancy: BMI 27.6 Current BMI: 29.9 Click to highlight the findings that require follow-up
H&P: Last pregnancy resulted in preterm spontaneous vaginal birth at 30 weeks gestation Nurses note: Day 1 0900: Client report lower back pain and pinkish vaginal discharge Uterine con every 8 minutes, palpate strong duration 30 sec Cervical exam indicates 2 cm, 50% effaced, 0 station
A nurse is caring for a client who has been admitted the antepartum unit 0900: 30 yr old client at 33 weeks gestation, gravida 4 para 3 maternal blood type Rh+. last pregnancy results in a preterm spontaneous vaginal birth at 30 weeks gestation click to highlight the findings that require a f/u
H&P: Last pregnant results in a preterm spontaneous vaginal birth at 30 weeks gestation Nurses Notes: Client reports lower back pain and pinkish vaginal discharge
The nurse reviews the entries in the medical record Provider Prescriptions: 0.9 sodium chloride 500ml bolus than 100ml/hr. Type and cross match for 2 units of packed RBCs, Repeat WBC, hemoglobin, hematocrit STAT, Delay endoscopy, 2L/min via nasal cannula............. The nurse is preparing the client for blood transfusion. which of the following actions should the nurse take? Select all that apply
Have a second nurse confirm the information on the blood label Insert a large bore IV catheter Witness the client signing a consent for transfusion
A nurse is caring for a client who is postoperative following a right hip arthroplasty For each assessment finding, click to specify if the finding is consistent with malignant hyperthermia, latex allergy, hypovolemic shock
Hypercapnia: Malignant, latex, hypovolemic Muscle rigidity: malignant, hypovolemic Tachycardia: Malignant, Latex, hypovolemic Urticaria: Latex Wheezes: Malignant, Latex
A nurse assisting with the care of a client in an outpatient providers office Assessment: 3 months ago No acute distress, breath sounds clear bilateral, no edema. 1 month ago: fatigue, breath sounds clear bilateral, 1+ bilateral lower extremity edema Today: Fatigue, weakness, hiccups, coarse thinning hair.... The nurse should identify that the client is at risk for developing
Iron deficiency anemia and may require a blood transfusion
A nurse is caring for a postoperative client following a perineal prostatectomy. For each potential providers prescription, click to specify if the potential prescriptions is anticipated or contraindicated for the client
Irrigate indwelling urinary catheter with 50 Ml of normal saline: anticipated Administer enema to relieve constipation: Contraindicated Maintain bed rest for 2 days postoperatively: Contraindicated Place a blanket roll under the clients knee while in bed: Contraindicated Apply warm compresses to the incision site: Anticipated
A nurse in an emergency department is caring for a client H&P 0400: 57 year old male client presents to the severe abdominal and epigastric pain that began about 12 hr ago. Pain 7/10, reports pain worsens after eating and radiates into his back. Nauseous and has had several episodes of vomiting.......Consumed 3 to 4 alcohol drinks per day...... The nurse should first address the clients _____ followed by the clients___
Lung sounds Temperature
Q168: A nurse is assisting with the care of a client Vital signs: 1330 Temp 36.8C, HR: 88/min Respiratory: 16/min BP: 110/64 1345: O2 sat: 96 with 3L/min via simple face mask ......................... For each data collection finding: click to specify if the finding is consistent with malignant hyperthermia, latex allergy, hypovolemic shock
Malignant hyper: muscle rigidity, hypercapnia, tachycardia Latex allergy: wheezes, urticaria Hypovolemic shock: tachycardia
A nurse is caring for a postpartum client in an outpatient setting. Complete the following sentence by using the list of options The client is at highest risk for developing ______ evidenced by____
Mastitis cracked nipples
Q:158 A nurse assisting with the care of a client who presents to the labor and delivery unit. Nurses note: 1700: client reports sudden onset of severe abdominal pain and vaginal bleeding/ moderate amount of dark red blood noted on the perineal pad. Abdominal rigid and tender to touch. Fetal HR: 125/min. 1715: contraction frequency 1.5-2 min Duration 60-90 sec, strong to palpation. etc...... Nurse assisting with clients care should expect which of the following prescriptions from the clients provider? (SATA)
Monitor vital signs at least every 15 mins obtain type and crossmatch measure blood loss by weighing pads insert a large-bore IV catheter
The nurse continues to care for the client Nurses notes: Day 1 0900: Client reports low back pain and pinkish vaginal discharge, uterine contractions every 8 minutes palpate strong duration 30 seconds. FHR baseline 145, minimal variability 0930: Peripheral IV initiated, 1000: Client voided and reports pain and discomfort upon urination Click the highlight findings that indicate improvement in the clients condition
Nurses note: Client rates lower back pain a 0 on a pain scale of 0-10 No reports of vaginal discharge Membranes intact No uterine contractions noted No further reports of burning with urination Lab results: Platelet count 188,000 Vital signs Temp 98.7 BP: 120/78
A nurse in an emergency department is caring for a client H&P 0400: 57 year old male client presents to the severe abdominal and epigastric pain that began about 12 hr ago. Pain 7/10, reports pain worsens after eating and radiates into his back. Nauseous and has had several episodes of vomiting.......Consumed 3 to 4 alcohol drinks per day...... For each finding, click to specify if the finding is consistent with pancreatitis or peritonitis
Pancreatitis: Hyperbilirubinemia, abdominal pain, Elevated WBC count Peritonitis: Bloody stools, abdominal pain, elevated WBC count
A nurse is caring for a client who has a spinal cord injury For each potential nursing action, click to specify if the action is anticipated or contraindicated for the clients
Perform suctioning: Contraindicated Assess for urinary retention: Anticipated Assess blood pressure every 15 min: Anticipated Withhold pain medication for headache until other manifestations resolve: Contraindicated Place client in supine position: Contraindicated Administer nifedipine: Anticipated
A nurse is caring for a client who has been admitted in the antepartum unit Vital signs: Day 1 0900: Admission: temp 101.1 F HR: 92 Respiratory rate: 18 BP: 13078 Pre-pregnancy: BMI 27.6 Current BMI: 29.9 For each potential prescription click to specify if the potential prescription is anticipated or unanticipated for the client
Place client in supine position: unanticipated Limit fluid intake to 3,000 ml/day: anticipated Administer oxygen: unanticipated Maintain bed rest with bathroom privileges: anticipated Administer betamethasone: Anticipated Administer terbutaline: Anticipated
Q 166; A nurse is assisting with the care of a client who is in active labor 1130: client admitted to labor and delivery. gravida 1 para 0 at 40 weeks of gestation. client presents with contractions every 5 to 6 min 30 to 40 seconds duration, 2+ intensity, client reports their water broke and the fluid was clear. The nurse is assisting with the care of client following insertion of an epidural For each nursing intervention click to specify if the intervention is essential or contraindicated for the client
Place the client in left lateral position: essential Decrease the IV flow rate: contraindicated Assist with administration of ampicillin 1: essential Monitor fetal heart rate: essential Request a prescription for ephedrine: ( it was blank on doc)
A nurse is an outpatient clinic is caring for a client Admission assessment: Day 1: 0800 Client reports increasing pain in their right knee and left wrist over the last 2 years Complete diagram by dragging from the choices below to specify what condition the client is most likely experiencing
Potential Condition: Osteoarthritis Actions to be take: Instruct the client to apply topical analgesics, Instruct the client to apply heat and cold Parameters to monitor: ESR, lymphadenopathy
A nurse is caring for a client in an ER Nurses notes: day 1 0400: client brought in by emergency medical services after being found roaming around the college and yelling, client ran from EMS shouting " No, you are not going to kill me."................ Complete the diagram by dragging from the choices below
Potential complication: Brief psychotic disorder Actions to take: Reduce stimuli, engage with client parameters to monitor: Ability to care for self, suicide risk
A nurse is caring for a 75 year old client who is admitted to the medical surgical unit Nurses notes: 0700: Received change of shift report, client is 2 days postoperative following a hysterectomy and they have not yet ambulated with physical therapy due to significant postoperative pain. Per change of shift report, pain medications have been adjusted and pain has improved...... Complete diagram by dragging from the choices below to specify what condition the client is most likely experiencing
Potential complication: DVD Actions to take: Homans sign, Dopler Parameter to monitor: PT/INR, signs of bleeding
Q164: Nurse note: 0900 Client is at 31 gestation and presents with severe headache unrelieved by acetaminophen. Reports urinary frequency and decreased fetal movement, client is gravida 3, para 2 with one preterm birth Report constant and throbbing headache and rate pain 6 on a scale of 10. Denies visual disturbances, +3 pitting edema lower extremities........... For each finding click to specify if the finding is consistent with preeclampsia or HELLP syndrome
Pre eclampsia: Blood pressure, platelet count HELLP syndrome: hemoglobin, platelet count, alanine aminotransferase
A172 A nurse is assisting in the care of an older adult client who was admitted from long term care facility. 1400: client hx includes cigarette smoking for 50 years by quit 3 years ago, Parkinson disease and anxiety 1500: client is restless and diaphoretic Respiratory rate is 28, O2: 88 room air, HR 110 bpn, Blood pressure: 180/110 Client confused and agitated...........etc Select the 3 findings that require immediate follow-up
Respiratory rate Oxygen saturation level Heart rate
A nurse is an ER caring for a client Diagnostic results: 1215: ECG Normal sinus rhythm 1250: Xray right arm: FX of right radius Click to highlight the findings that require immediate follow-up
Respiratory: Respiratory rate 11/min SpO2 94 on room air Musculoskeletal: Reports pain worsening in right forearm States right hand is tingly
Q162: The nurse continues to assist in the care of the client Day 5 0700: Ziprasidone 20 mg IM left deltoid muscle. Paliperidone 6mg PO Nurses notes: 2030: client appears with matted hair and staining of clothing attempting to get out of handcuffs. The client states I have to get out of here i hear helicopters, they are coming to get me. My name is Jamie and you are the devil......(same as question 161 ) Nurse collecting data from client 5 days after admission For each finding: click to specify whether the finding indicated the clients condition has improved or declined
Response to other clients Sleep pattern Hygiene patterns
A nurse is an ER caring for a client Nurses notes: Client is an 82 year old male who presents with his adult child for evaluation of right arm pain after a fall, Noted to have several superficial abrasions on right forearm and elbow, also has numerous bruises in various stages of healing on arms and upper chest. 1210: Client noted to keep head down and makes limited eye contact. speaks very softly and looks at adult child before answering............... The nurse should first address the clients ________ and ________
Safety Pain
A nurse is caring for a client in a clinic Nurses notes: 0900 16 year old clients reports to the clinic with their caregiver. the clients caregiver informs the nurse that the client has not been themselves lately. Clients parents and a sibling passed away from injuries sustained when a tornado moved through their town a month ago, they were the only survivors............... Based on the information in the clients medical record, which of the following findings require immediate f/u? Select 4 findings
Smoking marijuana to clear their mind HR: 99/min Client experiences nightmares Witnessing their family's death
A nurse is caring fora client who is admitted to the medical surgery unit Admission: 0900: Client reports "I'm bloated and my stomach hurts." History of prior illness: Client reports a 3 week history of gnawing abdominal pain. Client states, " its a burning sensation that radiates to my back....Reports one episode of dark, tarry stools, no vomiting. Reports pain is worse 1 hr after eating....... The nurse reviews the clients laboratory findings and vital signs. Select the 5 findings that require immediate follow-up
Stool results Hemoglobin and hematocrit Heart rate Current medications Blood pressure
A nurse is caring for a newborn 0640 Temp 98.1 F axillary HR: 154/min Respiratoty rate 68/min BP: 72/48 0650 HR: 156/min Respiratory rate 72/min 0700: Temp 98.6 F Axillary HR: 156/min Respiratory rate 76/min Drag words from the choices The client is at risk for developing _______and __________
Tachypnea Hypoglycemia
A nurse is an ER caring for a client Diagnostic results: 1215: ECG Normal sinus rhythm 1250: Xray right arm: FX of right radius A nurse is an outpatient orthopedic clinic is caring for the client six weeks following surgical repair of a Fx radius. Which of the following information provided by the client indicated improvement? Select all that apply
The client makes eye contact and smiles when speaking The clients adult child prepares two meals per day for the client The client clothing is clean and appropriate for the weather The client had gained 1.8kg (4lb) BMI 18.9 The client receives three baths per week from a home care aide
Q159: A nurse is assisting with the care of a client. Nurse notes: 0900: client reports a 3 month history of a intermittent diarrhea and abdominal pain. reports unintentional weight loss of 5.5kg (12lbs) in 3 months 0930: stool sample obtained fecal occult blood test ( fatty and appearance and foul odor noted) For each finding, click and specify if the finding is consistent with: ulcerative colitis, diverticulitis, or Crohns disease?
Ulcerative colitis: Abdomen cramping, weight loss, diarrhea, anemia Diverticulitis: abdomen cramping Crohn's disease: Abdomen cramping, weight loss, diarrhea, anemia
The nurse continues to care for the client Nurses notes: Day 1 0900: Client reports low back pain and pinkish vaginal discharge, uterine contractions every 8 minutes palpate strong duration 30 seconds. FHR baseline 145, minimal variability 0930: Peripheral IV initiated, 1000: Client voided and reports pain and discomfort upon urination Which of the following actions should the nurse take?
Urine culture Obtain provider prescription for antibiotics
A nurse is caring for a client in the medical surgical unit I&O: 1900: 750 ml intake over 12 hr, 650 ml urine output over 12 hr Which of the following actions should the nurse take to decrease the risks for urinary tract infection for this client? (SATA)
Use soap and water to provide perineal care Review the need for the indwelling urinary catheter daily Encourage the client to drink 3000mL of fluid daily
A nurse is an emergency department is caring for a client Vital signs: 1200: Temp 98 F HR: 96/min Blood pressure: 142/96 Resp: 16 O2 saturation:97% at room air Click to highlight the findings the nurse should report to the provider
Vital signs: BP: 142/96 Nurses notes: Client noted to have several superficial abrasions on right forearm and elbow. Has numerous bruises in various stages of healing on arms and upper chest Client rates pain in right lower forearm an 5 on a 0 to 10 pain scale and is not moving arm
A nurse is caring for a client. Week 1: WBC count 8,000 Platelet count: 350,000 Potassium: 3.7 Week 2: WBC count 3,800 Platelet count: 150,000 Potassium: 3.6 A nurse reviewing the clients electronic medical record, Which is the following findings require follow-up? Select all that apply
WBC, Temperature, Breath sounds, Blood pressure
The nurse assisting in the care of the client who is on the behavioral health unit. Nurses notes: 2015: 2030: client appears dishevels with matted hair and stained clothing. Client states I have to get out of here, i hear helicopters. They are coming to get me, My name is Jamie and you are the devil." Client appears to be responding to internal stimuli but is less outwardly agitated The client is exhibiting _____ as evidences by _______
visual hallucinations verbal statements
