Exit Rn part 2

D Risk for self directed violence as evidenced by feelings of hopelessness."

A client is admitted with abdominal pain, loss of appetite, and a weight loss of 25 lbs (11 kg) in the last 4 months. During the admission assessment, the clien describes to the nurse of having no interest in playing cards with friends anymore, and feels worthless most days. Which nursing problem should the nurse address first? • A "Imbalanced nutrition as evidenced by 25 lb (11 kg) weight loss in four months." • B "Chronic low self esteem as evidenced by feelings of worthlessness." • C "Anxiety as evidenced by abdominal discomfort secondary to depression." • D Risk for self directed violence as evidenced by feelings of hopelessness."

A Mental status changes.

A client is receiving a hypotonic solution for bladder irrigation and is at risk for dilutional hyponatremia. The nurse should plan to observe for which common sig of hyponatremia? • A Mental status changes. • B Muscle spasms. • C Irregular heart beats. • D Bradycardia. lose lot text and dald mining. Al training, and sirmilar

2 tablespoons

A client receives a prescription for acetaminophen 1,000 mg PO every 8 hours PRN for pain. The bottle is labeled "Acetaminophen for Oral Suspension, USP 500 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)

C Tell the client to discuss the medication side effects with the healthcare provider (HCP).

A client who experiences recurrent episodes of depression tells the nurse of a desire to discontinue the prescribed antidepressant. The client describes feeling the nurse to provide? less depressed after taking the medication for the past couple of weeks and the client does not like the side effects of the medication. Which response is best fo • A Inform the client that gradual tapering must be used to discontinue the medication. • B Tell the client that the medication's side effects will most likely dissipate over time. • C Tell the client to discuss the medication side effects with the healthcare provider (HCP). • D Remind the client that feeling better is the therapeutic effect of the medication.

A Increased appetite.

A client who is HiV positive receives a prescription for megestrol 400 mg daily. Which finding should the nurse identify as a therapeutic response to thi prescription? • A Increased appetite. • B Reduced serum viral load • C Healing skin lesions. • D No signs of thrombophlebitis.

B Do not allow the feeding to sit at room temperature.

A client who is homebound and is receiving continuous feedings through a gastrostomy tube reports experiencing frequent diarrhea. Which instructions should the nurse provide A Decrease the rate at which the feeding is given. ( B Do not allow the feeding to sit at room temperature. ( C Increase the concentration of the teedings. • D Elevate the head of the bed to ninety degrees.

• A Complete blood count

A client who is receiving zidovudine reports the appearance of pinpoint, red, round spots on the skin. Which result should the nurse report to the healthcare provider (HCP)? • A Complete blood count. • B Skin biopsy. • C Electromyography. • D Allergy test.

• B Withhold the preoperative medication.

A client who is scheduled for an elective inguinal hernia repair today in day surgery is seen eating in the waiting area. Which action should be taken by the nurse who is preparing to administer the preoperative medications? • A Review the surgical consent with the client. • B Withhold the preoperative medication. • C Remove the food from the client. • D Explain that vomiting can occur during surgery.

A Obtain a complete set of vital signs.

A client whose hyperthyroidism has not been responsive to medications is admitted for evaluation. During the admission assessment the client reports to the nurse of a sudden onset of feeling apprehensive and the nurse notes the client is restless and very warm to touch. Which action should the nurse implement next • A Obtain a complete set of vital signs. • B Encourage relaxation and slow deep breathing. • C Access laboratory results to confirm a thyroid crisis. • D Initiate peripheral IV (PIV) access

B Decrease consumption of red meat and most seafood.

A client with a history of gout presents to the clinic with an inflamed left knee. The client reports the knee is extremely painful to touch for the second time in 6 months. The healthcare provider (HCP) prescribes colchicine and ibuprofen. Which instruction should the nurse include in the discharge teaching? • A Support joints in an extended position while resting. • B Decrease consumption of red meat and most seafood. • C Replace dietary table salt with salt substitutes. • D Massage joints to relax muscles and decrease pain.

• A Determine if the client is using a new insulin needle each administration. • B Have the client demonstrate technique used to monitor blood glucose levels • C Have the client describe a typical day at work, home, and social activities. E Evaluate the client's asthma medications that can elevate the blood glucose.

A client with a history of type 1 diabetes mellius (DM) and asthma is readmitted to the unit for the third time in two months with a current fasting blood (FBS) of 325 mg/dL (18 mmol/). The client veralizes to the nurse of not understanding why the blood glucose level continues to be out of control. Which a r intervention(s) should the nurse implement? Select all that apply. Reference Rang lood Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L • A Determine if the client is using a new insulin needle each administration. • B Have the client demonstrate technique used to monitor blood glucose levels • C Have the client describe a typical day at work, home, and social activities. • D Ask the client if they want a different manufacturer's glucose monitoring device. • E Evaluate the client's asthma medications that can elevate the blood glucose.

C Inhaled short-acting beta-2 agonists.

A client with acute asthma exacerbation is manifesting inspiratory and expiratory wheezes and a decreased forced expiratory volume. Which prescribed drug class should the nurse administer first to the client? • A Anticholinergics. • B Leukotriene modifiers. • C Inhaled short-acting beta-2 agonists. • D Inhaled corticosteroids.

C Liquid brown drainage from stoma.

A client with bladder cancer had surgical placement of a ureteroileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider (HCP) immediately? • A Stomal output of 40 mL in the last hour. • B Red edematous stomal appearance. • C Liquid brown drainage from stoma. • D Mucous strings floating in the drainage.

A Focus on small achievable tasks, not taxing problems.

A client with generalized anxiety disorder does not want to communicate with friends, smokes 2 to 3 packages of cigarettes a day, and describes difficulty concentrating at work. Which coping strategy should the nurse include in the plan of care (POC)? A Focus on small achievable tasks, not taxing problems. B Concentrate on and ventilate emotions when distressed. C Relax and reduce the amount of effort to solve the problem. D Analyze past hurts and resentments to identify the source.

B Evaluate daily blood clotting factors

A client with rapid respirations and audible rhonchi is admitted to the intensive care unit (ICU) because of a pulmonary embolism (PE).Low-flow oxygen by nas cannula and weight based heparin protocol is initiated. Which intervention is most important for the nurse to include in this client's plan of care (POC)? • A Monitor deep vein blood flow using Doppler • B Evaluate daily blood clotting factors • C Apply antiembolism stockings. • D Maintain strict bed rest.

• D Auscultate lung and heart sounds

A female client with a history of heart failure (HF) arrives at the clinic after what she describes as a very long trip. Following the initial physical assessment and chart review, which priority action should the nurse implement? (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client's medical record.) • A Reteach medication regimen. • B Give a potassium supplement. • C Administer the prescribed diuretic. • D Auscultate lung and heart sounds

• C Both the sun and radiation can damage the skin because it has a rapid renewal rate. • D Shielding helps to localize the entrance of RT and protects other sensitive areas. • E Special gels can be prescribed for local application to promote healing and comfort.

A female client with breast cancer is scheduled to receive a series of radiotherapy (RT). She has red hair, fair skin, and freckles. She tells the nurse that her skin is particularly sensitive to the sun, so she is worried that the radiation will adversely affect her skin. Which information should the nurse provide this client about RT? Select all that apply. • A lonizing energy of RT penetrates to the target tumor and does not affect the skin like sun rays. • B Application of cold compresses after treatment decreases the skin's sensitivity. • C Both the sun and radiation can damage the skin because it has a rapid renewal rate. • D Shielding helps to localize the entrance of RT and protects other sensitive areas. • E Special gels can be prescribed for local application to promote healing and comfort.

Answer: D. Redirect the client's acting out behavior by asking him to perform a unit task.

A group of nursing students is touring an in-patient psychiatric unit when a male client who is in a manic state shouts, "Want to see a crazy person?" and begins to jump up and down, flap his arms, and cluck like a chicken. Which action is best for the nurse to take? A Direct the students to continue the tour without responding to the client's behavior. B Medicate the client with a PRN prescription for an antianxiety agent. C Restrict the client to his room until he can control his behaviors. D Redirect the client's acting out behavior by asking him to perform a unit task.

D Encourage the client to reflect on personal goals and priorities.

A middle-aged adult client, admitted to a critical care unit (CCU) several weeks ago because of serious injuries sustained in a motor vehicle collision, is currently in stable condition. Based on this client's age and recent life threatening crisis, which intervention should the nurse implement? • A Provide a routine schedule of activities to facilitate trust. • B Discuss the cause of the accident with the client and the client's family. • C Allow long periods of uninterrupted rest in order to reduce fatigue. • D Encourage the client to reflect on personal goals and priorities.

• C Last menstrual period was 7 weeks ago.

A young adult female presents at the emergency department (ED) with acute lower abdominal pain. Which assessment finding is most important for the nurse to eport to the healthcare provider (HCP)? • A Reports white, curdy vaginal discharge. • B History of irritable bowel syndrome (IBS). • C Last menstrual period was 7 weeks ago. • D Pain scale rating of a 9 on a 0 to 10 scale.

• C Remove resuscitation equipment from the room. • D Place a small pillow under the head. • E Gently close the eyes.

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which intervention(s) should the nurse take to prepare the body before the family enters the room? Select all that apply. • A Take out dentures and place in a labeled cup. • B Apply a body shroud. • C Remove resuscitation equipment from the room. • D Place a small pillow under the head. • E Gently close the eyes.

B Ease the client to the floor while holding the gait belt securely.

After applying a gait belt, the nurse assists a client with ambulation. While in the hallway, the client begins to fall. Which action should the nurse implement? A Use the gait belt to slowly guide the client back to the room. B Ease the client to the floor while holding the gait belt securely. C Support the client in an upright position until the belt is removed D Advise the client to grab hold of the gait belt for added support.

B Insert peripheral IV (PIV) catheter for venous access.

After multiple hospitalizations over the past 6 months, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy and reports bloody stools and poor appetite for 2 days. The vital sign are assessed as an oral temperature 100.5° F (38.1° C), heart rate 142 beats/minute, respirations shallow at 24 breaths/minute, blood pressure 80/50 mm Hg, and oxygen saturation 94% on 4 L/minute nasal cannula. Which intervention should the nurse implement? • A Increase the oxygen flow to 6 L/minute nasal cannula. • B Insert peripheral IV (PIV) catheter for venous access. • C Set up for synchronized cardioversion. • D Administer oral PRN dose of antipyretic.

A Range-of-motion and circulation.

An adolescent client on a drug treatment unit becomes angry and pulls the refrigerator from the wall and then throws the microwave. After the client fails to respond to redirection, the healthcare provider (HCP) prescribes restraints.Which assessment should the nurse include in the client's record while the client is in • A Range-of-motion and circulation. • B Pupils equal, round and reactive. • C Speech patterns and processes. • D Responsiveness to painful stimuli.

B Diminished bilateral breath sounds.

An adult male client is brought to the emergency department (ED) by ambulance following a motorcycle collision. He was not wearing a helmet and presents with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse? • A Rebound abdominal tenderness. B Diminished bilateral breath sounds. C Nausea with projectile vomiting. D Rib pain with deep inspiration.

1.3 mL

An infant who weighs 22 Ibs. receives a prescription for amoxicillin 20 mg/kg/day PO in divided doses every 8 hours. The bottle is labeled, "Amoxicillin for Oral Suspension, USP 250 mg per 5 mL." How many mL should the nurse administer with each dose? (Enter numerical value only. If rounding is necessary, round to the nearest tenth.)

B Daily use of spironolactone for hypertension.

An older adult client is admitted with pneumonia, and the healthcare provider (HCP) prescribes penicillinG potassium IV. Which assessment finding increases the risk of adverse reactions in this client? A Previous treatment with penicillin for pneumonia. B Daily use of spironolactone for hypertension. • C Documented allergy to sulfonamides. • D Sputum culture results of Streptococcus pneumoniae.

D Keep the IV access line intact for diuretic administration.

An older adult client is receiving a second unit of packed red blood cells (PRBCs) when the nurse enters the room and finds the client sitting up in bed. The clien is dyspneic and seems confused. Lung auscultation reveals crackles in the bases of both lungs. Vital sign measurement reveals a rapid, bounding pulse anc elevated blood pressure. After discontinuing the transfusion, which intervention should the nurse implement • A Monitor for hives and pruritus • B Obtain a urine specimen. • C Send the PRBC bag and blood tubing to the blood bank • D Keep the IV access line intact for diuretic administration.

• A Determine number of sexual partners she has had recently. • B Inquire if she is being emotionally or physically abused. E Review list of daily medications for aspirin or other anticoagulants.

An older adult female client who resides at an assisted living facility comes for an annual gynecological visit at the clinic and states she has a burning sensatior when urinating. Assessment findings are a blood pressure of 128/88 mm Hg, urine negative for bacteria, and ecchymotic areas on both forearms. She reports being sexually active and drinks beer once or twice a month. During this clinic visit, which intervention(s) should the nurse implement? select all that apply. • A Determine number of sexual partners she has had recently. • B Inquire if she is being emotionally or physically abused. • C Question her if she previously or currently uses of any illicit drugs. D Ask the client if somgone brought her to the clinic. E Review list of daily medications for aspirin or other anticoagulants.

A Report the eye pain to the surgeon.

Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye. Which action should the nurse take? • A Report the eye pain to the surgeon. • B Administer an antiemetic to prevent vomiting. • C Apply bilateral eye shields to reduce photosensitivity. • D Begin postoperative prophylactic antibiotics.

D Observe both lower extremities for redness and swelling.

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete? • A Monitor the amount of drainage from the client's incision. • B Evaluate the client's ability to use an incentive spirometer. • C Palpate all peripheral pulse points for volume and strength. • D Observe both lower extremities for redness and swelling.

B Daily weight decrease of 2 lb (0.9 kg).

The healthcare provider (HCP) prescribed furosemide for a 4-year-old child who has a ventricular septal defect. Which outcome indicates to the nurse that this pharmacological intervention was effective? Reference Range: Blood Urea Nitrogen (BUN) [5 to 18 mg/dL (1.8 to 6.4 mmol/L)] Urine Specific Gravity [1.005 to 1.03] • A BUN increase from 8 to 12 mg/dL (2.9 to 4.3 mmol/L). • B Daily weight decrease of 2 lb (0.9 kg). • C Urine specific gravity change from 1.021 to 1.031. • D Urinary output decrease of 5 mL/hour.

25 gtt/min

The healthcare provider (HCP) prescribes 500 mL of 0.45% normal saline with 100 units regular insulin to infuse at 15 units/hour. The drop factor is 20 gtt/mL. The nurse should regulate the IV to deliver how many gtt/minute? (Enter numerical value only.)

A Use recliner for long periods of sitting. B Continue wearing compression stockings D Avoid prolonged standing or sitting.

The home care nurse provided self care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. Which instruction(S) should the nurse include in the client's discharge teaching plan? Select all that apply. A Use recliner for long periods of sitting. B Continue wearing compression stockings. C Cross legs at knee but not at ankle. D Avoid prolonged standing or sitting. • E Maintain the bed flat while sleeping.

C Assess for signs of fluid volume deficit.

The nurse assumes care of a postoperative adult client with type 2 diabetes mellitus and learns that the client has a current blood glucose level of 750 mg/dL (4: mmol/L). When assessing the client, which is the priority? Reference Range: Fasting blood glucose [70 to 110 mg/dL (3.9 to 6.1 mmol/L)] • A Determine when the client last ate. • B Measure the level of acute pain. • C Assess for signs of fluid volume deficit. • D Observe wound drainage characteristics

• D Fluid volume deficit.

The nurse identifies several nursing problems for a client with tetraplegia who is experiencing fecal incontinence and diarrhea. The client's spouse is the primary caregiver. In planning care, which identified nursing problem has the highest priority? • A Bowel incontinence. • B Caregiver role strain • C Impaired bed mobility. • D Fluid volume deficit.

D Ask the client to describe the pain.

The nurse is caring for a client who has been admitted with recurring migraine headaches. To assess the quality of the client's pain experienced from the migraine headache, which approach should the nurse use? • A Identify effective pain relief measures. • B Provide a numeric pain scale. • C Observe body language and movement. • D Ask the client to describe the pain.

B Start two large bore peripheral IV (PIV) catheters and review inclusion criteria for IV fibrinolytic therapy.

The nurse is caring for a client who reports sudden right sided numbness and weakness of the arm and leg. The nurse also observes a distinct right sided facial droop. After reporting the findings to the healthcare provider (HCP), the nurse receives several prescriptions for the client, including a STAT computerized tomography (CT) scan of the head. Which action should the nurse take first? * A Raise the head of the bed to 30° keeping head and neck in neutral alignment. * B Start two large bore peripheral IV (PIV) catheters and review inclusion criteria for IV fibrinolytic therapy. * C Administer aspirin to prevent further clot formation and platelet clumping. * D Begin continuous observation for transient episodes of neurologic dysfunction

A Raise the head of the bed to 30° keeping head and neck in neutral alignment.

The nurse is caring for a client who reports sudden right sided numbness and weakness of the arm and leg. The nurse also observes a distinct right sided facial droop. After reporting the findings to the healthcare provider (HCP), the nurse receives several prescriptions for the client, including a STAT computerized tomography (CT) scan of the head. Which action should the nurse take first? • A Raise the head of the bed to 30° keeping head and neck in neutral alignment. • B Start two large bore peripheral IV (PIV) catheters and review inclusion criteria for IV fibrinolytic therapy. • C Administer aspirin to prevent further clot formation and platelet clumping. • D Begin continuous observation for transient episodes of neurologic dysfunction.

B Provide a bedside commode for toileting.

The nurse is developing a plan of care (POC) for a client with cardiomyopathy. Which intervention should the nurse include to reduce cardiac workload? • A Assist with ambulation in the hallway. • B Provide a bedside commode for toileting. • C Encourage active range of motion exercises. • D Teach to sleep in a side-lying position.

Keep head of bed at 30

The nurse is monitoring a client with Cushing's disease in the postanesthesia care unit (PACU) after a hypophysectomy. Which intervention is most important fol the nurse to include in the client's plan of care (POC)? • A Provide frequent mouth care. • B Keep head of bed at 30°. • C Monitor intakeignd output. • D Maintain nasal packing. FInc, Its licensors, and contributors. All rights are

C Notify your healthcare provider (HCP) if you start having abdominal pain.

The nurse is planning discharge instructions for a client with type 2 diabetes mellitus who will be starting exenatide. Which information should be included in the discharge instructions? • A There are no precautions about taking exenatide with other medications. • B Exenatide cts in the same way as insulin in lowering blood glucose. ) C Notify your healthcare provider (HCP) if you start having abdominal pain. ) D Inject exenatide within 30 minutes before or after a meal.

B Wash the residual limb with soap and water C Use a residual limb shrinker D Inspect skin for redness.

The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendations) should the nurse provide this client? Select all that apply. A Avoid range of motion exercises B Wash the residual limb with soap and water C Use a residual limb shrinker D Inspect skin for redness. E Apply alcohol to the residual limb after bathing

D Divide the medication into two injections with volumes under 1 mL.

The nurse is preparing to administer 1.6 mL of medication IM to a 4-month-old infant. Which action should the nurse include? • A Select a 22 gauge 1 1/2 inch (3.8 cm) needle for the intramuscular injection. • B Administer into the deltoid muscle while the parent holds the infant securely. • C Use a quick dart like motion to inject into the dorsogluteal site • D Divide the medication into two injections with volumes under 1 mL.

Call if the hernia changes color.

The nurse is providing home management education to parents of an infant with an inguinal hernia. Which instruction should the nurse provide? • A Place restrictions on leg activity. • B Report night time irritability. • C Call if the hernia changes color. • D Tape the hernia in place.

B Abdominal perineal resection 2 days ago with no drainage on dressing who has fever and chills.

The nurse who is working on a surgical unit receives change of shift report on a group of clients for the upcoming shift. A client with which condition requires immediate attention by the nurse? A Mastectomy 2 days ago with 50 mL bloody drainage noted in the bulb drainage system. B Abdominal perineal resection 2 days ago with no drainage on dressing who has fever and chills. C Collapsed lung after a fall 8 hours ago with 100 mL blood in the chest tube collection container. D Gunshot wound three hours ago with dark drainage of 2 cm noted on the dressing.

C Assess the level of consciousness and vital signs for both clients.

The nurse working in a critical care unit (CCU) is assigned the care of two clients, one with pneumonia who is being mechanically ventilated and the other who had a thoracotomy yesterday and is reporting incisional pain. Which action(s) should the nurse perform first? • A Change the surgical dressing to observe the appearance of the incision. • B Review the plan of care and the medications that are due for both clients. • C Assess the level of consciousness and vital signs for both clients. • D Complete a head-to-toe assessment of the client with pneumonia.

• D Begin chest compressions at a rate of 100 to 120 per minute.

When the nurse enters the room of a male client who was admitted for a fractured femur, his cardiac monitor displays a normal sinus rhythm (NSR), but he has nc spontaneous respirations and his carotid pulse is not palpable. Which intervention should the nurse implement? • A Observe for swelling at the fracture site. • B Analyze the cardiac rhythm in another lead. • C Obtain a 12-lead electrocardiogram. • D Begin chest compressions at a rate of 100 to 120 per minute.

A Request a culture and sensitivity offhe wound.

While caring for a client's postoperative dressing, the nurse observes purulent wound drainage. Previously, the wound was inflamed and tender but without drainage. Which is the most important action for the nurse to take? A Request a culture and sensitivity offhe wound. • B Determine if the drainage has an unpleasant odor. • C Monitor the client's white blood cell count (WBC). • D Cleanse the wound with a sterile saline solution.

Note date and time of the behavior. Discuss the issue privately with the UAP Plan for scheduled break times Evaluate the UAP for signs of improvement.

an unlicensed assistive personnel (Jar) leaves the unit without notying ine stan. In wich order snould the unit manager Implement these Interventions ddress the UAP's behavior? (Place the actions in order from first on top to last on bottom. Evaluate the UAP for signs of improvement. Discuss the issue privately with the UAP Plan for scheduled break times. Note date and time of the behavior.

D An upset stomach may occur as a side effect of this medication.

client diagnosed with Parkinson's disease receives a prescription for carbidopa-levodopa, controlled release (CR) 25/100 mg PO daily each morning. Which information should the nurse include in the client's teaching plan? Select all that apply. A Parkinson symptoms should diminish within one week. B Avoid sunlight and wear sunglasses while outdoors. C A change in urine color to dark red often occurs while taking this drug. D An upset stomach may occur as a side effect of this medication. E The medication should only be taken during a meal.

B Wear protective goggles while performing the procedure.

client is having difficulty coughing up thick mucus and requires suctioning. When suctioning the client with a Yankauer suction catheter, which action should the nurse include? • A Apply a water soluble lubricant to the catheter. • B Wear protective goggles while performing the procedure. • C Instill 3 mL of normal saline before suctioning. • D Instruct the client to cough as the suction tip is removed

A Monitor cardiac rhythm via telemetry. C Maintain record of fluid intake and output. D Schedule rest periods between activities. E Report changes in pre-existing murmurs.

male client with a history of mitral valve prolapse is admitted because of fever and dyspnea on exertion, and is diagnosed with acute infective endocarditi During the admission assessment, the nurse observes multiple areas of petechiae on the client's skin. Which interventions should the nurse include in the client' plan of care? (Select all that apply.) A Monitor cardiac rhythm via telemetry. B Initiate contact transmission precautions. C Maintain record of fluid intake and output. D Schedule rest periods between activities. E Report changes in pre-existing murmurs.

D Last dose and type of rescue inhaler used by the child.

parent brings their child, who has a history of asthma, to the emergency department (ED). The child is wheezing and speaking one word between each brea ne child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain' • A Type of allergen exposure or trigger for the current episode • B Type of inhaler the child typically uses on a regular basis. • C Frequency that the child uses a rescue inhaler during the week • D Last dose and type of rescue inhaler used by the child.

A The client should be monitored closely for persistent nausea or vomiting. • C A patient controlled analgesic (PCA) pump is prescribed and needs to be started as soon as possible. • D Surgical dressing is clean, dry, and intact and neurovascular status is WNLs.

The postanesthesia care unit (PACU) nurse uses the situation, background, assessment, recommendation (SBAR) format in reporting to the surgical unit nurse regarding an older adult client. The client is postoperative right total hip replacement for avascular necrosis. Vital signs are reported, which are all stable and within normal limits (WLs). The nurse also reports that the client was medicated for pain with morphine 2 mg IV push (IVP) and ondansetron 4 mg IVP 45 minutes ago, which reduced the pain level to 4 on a 0 to 10 scale, but the client is still nauseated. Which additional information is critical for the PACU nurse to include in the SBAR format report? Select all that apply. • A The client should be monitored closely for persistent nausea or vomiting. • B A large number of family members are in the surgical waiting area. • C A patient controlled analgesic (PCA) pump is prescribed and needs to be started as soon as possible. • D Surgical dressing is clean, dry, and intact and neurovascular status is WNLs. • E Client history includes heart failure (HF) and aphasia from a previous stroke.