ati b fundamentals

A nurse is discussing the use of herbal supplements for health promotion to a client. Which of the following client statements indicates an understanding of herbal supplement use?

"I can take echinacea to improve my immune system." Echinacea is taken to promote immunity and reduce the risk of infection.

A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make?

"People in middle adulthood often find satisfaction in nurturing and guiding young people."

a nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. which of the following instructions should the nurse provide to the client and his family?

1) check the cord routinely for frays or tearing 2) consider purchasing a generator for power backup 3) observe for signs of hypoxia Check the cord routinely for frays or tearing is correct. Oxygen concentrators require electrical power. Safe use of this delivery system includes assessing the electrical function of the device; therefore, the nurse should instruct the client to routinely check the condition of the cord.Keep the unit at least 1.2 m (4 feet) away from a gas stove is incorrect. Safe use of home oxygen equipment includes keeping the unit at least 3.05 m (10 feet) away from open flames, such as from a fireplace or a gas stove, and at least 2.4 m (8 feet) away from other heat sources.Consider purchasing a generator for power backup is correct. Loss of electricity prevents the oxygen concentrator from functioning and could deprive the client of necessary oxygen. The nurse should also instruct the family to have the client placed on their municipality's priority list for restoring power after an outage occurs.Observe for signs of hypoxia is correct. The nurse should instruct the family to observe for and report signs of hypoxia, such as anxiety, worsening fatigue, dizziness, rapid pulse and respirations, pallor, and cyanosis. Even with supplemental oxygen, the client's status can worsen, resulting in the development of hypoxia.Select synthetic clothing and bedding is incorrect. Safe use of oxygen therapy includes choosing clothing and bedding made from material that does not generate static electricity; therefore, the nurse should instruct the client to select materials made from cotton.

A nurse is preparing a heparin infusion for a client who was admitted to the facility with deep vein thrombosis. The prescription reads 25,000 units of heparin in 0.9% sodium chloride 250 mL to infuse as 800 units/hr. At what rate should the nurse set the infusion pump? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero

25,000units/2500mL = 800units/hr/x Cross multiply. 800 x 250 = 200,000 200,000 divided by 25,000 = 8 8 mL/hr

A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients?

A client who has asthma

A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?

A. "We can talk about advance directives, and I can also give you some brochures about them." With this statement, the nurse offers to provide the information the client needs in a direct and simple way.

A nurse is caring for a group of clients on a medical surgical unit. Which of the following situations does the nurse demonstrate the ethical principle of veracity?

A. A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. Following the ethical principle of veracity, the nurse must tell the truth at all times and never deceive others.

Nurses' Notes 1200:Client arrives to ED and reports abdominal pain and no bowel movement for the past 7 days. Client is undergoing chemotherapy for pancreatic cancer and has been taking 40 mg oxycodone extended-release tablets daily for the past 3 months. Client states they have attempted to relieve constipation for the last 7 days with bisacodyl suppositories and magnesium citrate oral suspension. Client reports that neither therapy initiated defecation.1230:Client transported for abdominal x-ray.1245:Client returned from x-ray. Provider prescribes a hypertonic cleansing enema.1300:Procedure explained to client who verbalized understanding. Diagnostic Results 1245:Abdominal x-ray indicates a large amount of fecal material throughout the colon. No evidence of gastrointestinal obstruction observed. Based on the client's clinical findings, which of the following actions should the nurse take?

A. Assist the client to a left side-lying position with the right knee flexed. C. Administer a cleansing enema. D. Auscultate the client's bowel sounds. E. Perform a manual digital examination of the client's rectum. Prepare the client for a chest x-ray is incorrect. A chest x-ray is typically performed for a client who has an impairment of the upper thorax or lungs, not the abdomen. The client has already received an abdominal x-ray; therefore, a chest x-ray is not necessary. Administer oxycodone extended-release tablets is incorrect. Although the client has a prescription for oxycodone to treat pain related to pancreatic cancer, opioid medications can cause the adverse effect of constipation. Because the client reports not having experienced a bowel movement for an extended period of time, the nurse should withhold further opioids until the cause of the client's constipation is determined. Prepare the client for NG tube placement is incorrect. The nurse should not prepare the client for placement of an NG tube because there is no indication or prescription to do so. Placement of an NG tube is required when there is an obstruction of the gastrointestinal tract and peristalsis is absent.

A nurse in the emergency department is caring for a client. Nurses' Notes 1100:Client arrives to ED and reports nausea, vomiting, and diarrhea for 3 days. Client is febrile.1110:Provider at bedside; prescriptions received.1115:IV initiated to right arm with 20-gauge catheter. Acetaminophen and metoclopramide administered.1200:Client appears fatigued, with no energy. Hair is thin and sparse. Cachectic, with flaccid muscle tone. Oriented x 3, able to move all extremities. Tachycardia, edema to lower extremities. Respirations unlabored, chest clear. Bowel sounds x 4 hyperactive, abdomen distended. Reports no difficulty with urination. Skin dry and scaly with bruises on extremities. Medication Administration Record 1115:Acetaminophen 650 mg rectal every 6 hr PRN temperature greater than 38.3° C (101° F)Metoclopramide 10 mg IV every 6 hr PRN nausea/vomiting Vital Signs 1100:Temperature 39.2° C (102.6° F)Pulse rate 118/minRespiratory rate 18/minBlood pressure 92/68 mm HgOxygen saturation 95%Weight 44.9 kg (99 lb)BMI 17 findings that indicate the client is malnourished.

A. Cachectic, with flaccid muscle tone. B. Skin dry and scaly with bruises on extremities. D. Pulse rate 118/min F. Abdomen distended H. BMI 17 Oriented x 3, able to move all extremities is incorrect. The client's neurological status is within expected parameters. Respiratory rate 18/min is incorrect. The client's respiratory rate is within the expected reference range. Temperature 39.2° C (102.6° F) is incorrect. An elevated temperature is not an indication of malnutrition.

A nurse is caring for a client who is receiving pain medication through a patient controlled analgesia pump. Which of the following actions should the nurse take?

A. Instruct the family to refrain from pushing the button for the client while she is asleep. The nurse should instruct family members not to activate the button for the client while they are sleeping. Even though PCA pumps minimize the risk of overdose, toxic effects could still occur if the client receives more medication than necessary to control pain.

A nurse is preforming a peripheral vascular assessment for a client, when placing the bell of the stethoscope on the clients neck, the nurse hears the following sound. This sound indicates which of the following?

A. Narrowed arterial lumen Blowing sounds resulting from blood flowing through occluded or narrowed arteries are known as a bruit.

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

A. Place the client in a room with negative-pressure airflow. B. Wear gloves when assisting the client with oral care. E. Use antimicrobial sanitizer for hand hygiene. Limit each visitor to 2-hr increments is incorrect. The nurse does not need to limit the client's visitors. However, the nurse should limit the client's presence outside the room and the client should wear a surgical mask when outside of the room.Wear a surgical mask when providing client care is incorrect. The nurse should wear an N95 respirator during client care to meet the requirements of airborne precautions.

Nurses' Notes 0930:Client reports a sore throat, productive cough, shortness of breath, and fever for the past 4 days.1030:Client has swollen lymph nodes of the neck upon palpation. Client reports chills and coughs up yellow-colored mucus. Client's face is flushed and diaphoretic. States lack of appetite. Chest x-ray obtained and positive for pneumonia. Vital Signs 1030:Blood pressure 110/68 mm HgHeart rate 110/minRespiratory rate 24/minTemperature 38.6° C (101.5° F)Oxygen saturation 91% on room air The nurse is reviewing the client's medical record. Which of the following actions should the nurse take?

A. Place the client on droplet isolation precautions. B. Apply oxygen at 2 L/min via nasal cannula. C. Request a prescription for an antipyretic medication. F. Remain 1 m (3 feet) from the client. Wear an N-95 mask when providing care to the client is incorrect. The nurse should wear an N-95 mask when providing care to clients who have an airborne infection and are in a negative air pressure room. Remain 1 m (3 feet) from the client is correct. The nurse should identify that the client has pneumonia. Therefore, the nurse should wear a sterile mask and remain within 1 m (3 feet) from the client.

Nurses' Notes Day 1:Client is alert and oriented to person, place, and time. Client has stage 2 pressure injury on coccyx. Wound tissue is pink with no drainage. Lungs clear on auscultation. Heart sounds are regular. +2 peripheral pulses and no presence of edema in lower extremities. Bowel sounds active x 4 quadrants. Client ate 50% of breakfast. Client reports pain to pressure injury as 2 on a scale of 0 to 10. Client repositioned every 2 hr while in bed.Day 4:Client has stage 2 pressure injury on coccyx. Wound tissue is yellow with purulent drainage. Wound has foul odor. Client ate 75% of breakfast. Client reports pain to pressure injury as 6 on a scale of 0 to 10. Client repositioned every 2 hr while in bed. Vital Signs Day 4:Temperature 38.3° C (101° F)Pulse rate 80/minRespiratory rate 20/minBlood pressure 128/64 mm HgOxygen saturation 93% on room air Diagnostic Results Day 4:Potassium 4.2 mEq/L (3.5 to 5 mEq/L)Hgb 13 g/dL (12 to 16 g/dL)Hct 38% (37% to 47%)WBC count 12,000/mm3 (5,000 to 10,000/mm3)Prealbumin12 mg/dL (15 to 36 mg/dL) Click to highlight the findings that the nurse should report to the provider.

A. Temperature B. WBC count C. Prealbumin level F. Pain level G. Odor of wound Hemoglobin level is incorrect. The client's hemoglobin is within the expected reference range. Therefore, the nurse does not need to report this finding to the provider. Blood pressure is incorrect. The client's blood pressure is within the expected reference range. Therefore, the nurse does not need to report this finding to the provider. Bowel sounds is incorrect. The client's bowel sounds are present in all four quadrants. Therefore, the nurse does not need to report this finding to the provider.

Nurses' Notes 0800:Client is 2 days postoperative following an ileostomy. Pouch is one-fourth full of stool. Stoma is red. Abdomen is soft and nontender. Bowel sounds present in all quadrants. 1200:Stoma site appears dark purple with blistering on the skin around the stoma. Pouch is slightly leaking and is three-fourths full of brown, liquid stool. Diagnostic Results 1200:Hgb 19 g/dL (12 to 16 g/dL)Hct 46% (37% to 47%) the nurse should first address the _____ followed by the ____

A. stoma color B. skin around the stoma Hemoglobin level is incorrect. The nurse should report the client's hemoglobin level because it is greater than the expected reference range. However, there is another finding that is a greater risk to the client and that the nurse should address first. Ostomy leakage is incorrect. The nurse should address the leakage around the client's stoma because it can cause irritation to the skin surrounding the stoma. However, there is another finding that is a greater risk to the client and that the nurse should address first. Ostomy pouch seal is incorrect. The nurse should address the ostomy pouch seal because it can cause irritation to the skin surrounding the stoma. However, there is another finding that is a greater risk to the client and that the nurse should address next. Amount of stool in the pouch is incorrect. The nurse should address the amount of stool in the client's pouch to avoid further leakage, which can cause irritation. However, there is another finding that is a greater risk to the client and that the nurse should address next.

a nurse is administering IV fluids to a client. when monitoring for adverse effects, which of the following assessments should the nurse identify as the priority?

Auscultate lung soundsThe priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid-volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles heard in lung fields, dyspnea, and shortness of breath.The nurse should measure urine output to monitor the renal function of an older adult client who is receiving IV fluid; however, it is not the priority assessment.The nurse should monitor blood pressure readings to evaluate the hemodynamic stability of an older adult client who is receiving IV fluid; however, it is not the priority assessment.The nurse should monitor serum electrolyte levels, especially sodium, to guide the planning of interventions to correct any imbalances in an older adult client who is receiving IV fluid; however, it is not the priority assessment.

A nurse is caring for a client who reports pain. When documenting the quality of the clients pain on an initial assessment, the nurse should record which of the following client statements?

B. "The pain is like a dull ache in my stomach." The client is describing the quality of the pain, which is how the pain feels in the client's own words.

A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record?

B. 0.3 mg The use and placement of a decimal point can potentially cause a medication error if documented incorrectly. A zero should precede a decimal point, as in 0.3 mg, but should not follow a decimal point unless a whole number follows the zero, as in 2.05 mg.

A community health nurse is checking blood pressures for a group of clients at a community health screening. Which of the following clients is at an increased risk for hypertension?

B. A client who smokes one pack of cigarettes each day

A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines?

B. A nurse asks a nurse from another unit to assist with documentation for a client. Only health care professionals directly caring for a client should have access to the client's medical information; therefore, this is a violation of HIPAA guidelines.

A nurse is planning care for a client who has tuberculosis. The nurse should use which of the following pieces of personal protective equipment when providing care for the client?

B. N95 respirator The nurse should wear an N95 respirator when providing care for a client who requires droplet precautions as a result of tuberculosis to prevent the transmission of bacteria

A nurse is caring for a client who had a spinal cord injury and has paraplegia. Nurses' Notes Day 1:Client is alert and oriented.Client is repositioned every 2 hr.Passive range-of-motion exercises to lower extremities performed once each day.Day 5:Client is alert and oriented.Client is repositioned every 2 hr. Passive range-of-motion exercises to lower extremities performed once each day.Feet warm. Pedal pulses 2+ bilaterally.Plantar flexion contractures noted bilaterally.Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact.

B. Passive range-of-motion exercises to lower extremities performed once each day. D. Plantar flexion contractures noted bilaterally. E. Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact. Client is repositioned every 2 hr is incorrect. The nurse should reposition the client every 2 hr to reduce the risk for skin breakdown. Therefore, this finding does not require intervention at this time. Feet warm. Pedal pulses 2+ bilaterally is incorrect. The nurse should identify that the client has adequate circulation to their feet. Therefore, this finding does not require intervention at this time

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take?

B. Select a suction catheter that is half the size of the lumen. to prevent hypoxemia an trauma

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The clients partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?

B. Withhold the blood transfusion. The principle of autonomy ensures that a client who is competent has the right to refuse treatment.

A nurse in a surgical suite notes documentation on a client's medical record he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?

B. Wrap monitoring cords with stockinette and tape them in place. Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the client's skin by covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to secure them.

A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid?

C. 8 oz of ice chips The nurse should document half of the volume of ice chips when calculating fluid intake to account for the air in between the chips. The nurse should understand that 4 oz of liquid water is equal to 120 mL of fluid.

A nurse is preforming a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use?

C. Have the client stand with their arms at their sides and their feet together. A Romberg test helps identify alterations in balance. The nurse should have the client stand with their arms at their sides and their feet together to observe for swaying and a loss of balance.

A nurse is reviewing a clients medication prescription that reads, "digoxin 0.25 by mouth every day" which of the following components of the prescription should the nurse verify with the provider?

C. Medication dose In the prescription, the medication dose is not complete. The number 0.25 should be followed by a unit of measurement, such as mg, to clarify the amount the nurse should administer.

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?

C. Rapid heart rate Tachycardia indicates fluid volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days.

A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating filtration?

C. Skin blanching Skin blanching, edema, and coolness at the IV site indicate infiltration.

Nurses' Notes​ 0800:Client 1: Client is admitted with a new diagnosis of rheumatoid arthritis.Client 2: Client has a history of hyperlipidemia. Atorvastatin 20 mg PO administered as prescribed.Client 3: Client is 1 day postoperative. Reports pain as 8 on a scale of 0 to 10. Morphine 5 mg subcutaneous administered as prescribed.Client 4: Client is admitted with a new diagnosis of heart failure.Client 5: Client has a stage 2 pressure injury on the left heel.Client 6: Client is admitted with a new diagnosis of diabetes mellitus. Diagnostic Results​ 0900:Client 1: C-reactive protein 3.2 mg/dL (less than 1.0 mg/dL)Client 2: Cholesterol 250 mg/dL (less than 200 mg/dL)Client 3: Oxygen saturation 88% (95% to 100%)Client 4: Potassium 3.2 mEq/L (3.5 to 5.0 mEq/L)Client 5: Prealbumin 14 mg/dL (15 to 36 mg/dL)Client 6: Glycosylated hemoglobin 8% (less than 7%) the first client the nurse should assess is ____ followed by ____.

C. client 3 A. client 4 Client 1 is incorrect. The nurse should assess this client because the client's C-reactive protein is greater than the expected reference range, which is an indication of inflammation. However, there is another client the nurse should assess first. Client 2 is incorrect. The nurse should assess this client because the client's cholesterol level is greater than the expected reference range, which places them at risk for coronary heart disease. However, there is another client the nurse should assess first. Client 5 is incorrect. The nurse should assess this client because their prealbumin level is less than the expected reference range, which places them at risk for delayed wound healing. However, this client is not the next priority client to assess. Client 6 is incorrect. The nurse should assess this client because their glycosylated hemoglobin level is greater than the expected reference range, which indicates poor diabetic control. However, this client is not the next priority client to assess.

A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include?

D. "You should receive a pneumococcal vaccine when you are 65 years old." The nurse should instruct older adult clients to receive one of the two pneumococcal vaccines when they are 65 years old. The vaccines can be given to clients who are 19 years of age and older and have certain conditions, such as chronic heart, lung, or liver disease, diabetes mellitus, and alcohol disease, or to those who smoke cigarettes

A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding?

D. Arrange food in a consistent pattern on the client's plate. Consistency in preparing the client's plate helps to facilitate self-feeding for clients who have vision loss. Staff can describe the location of the food on the plate by using a clock pattern, allowing the client to have greater independence during meals.

A nurse on a medical unit is preparing to discharge a client to home.Which of the following actions should the nurse take as part of the medication reconciliation process?

D. Compare prescriptions with medications the client received while at the facility. When performing medication reconciliation, the nurse should create a current, accurate list of every medication the client is or should be taking. Part of the process is comparing the medications the client received at the facility with those the provider has prescribed for the client to take after discharge

A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?

D. Distended neck veins Indications of fluid volume excess include distended neck veins, edema, tachycardia, crackles in the lungs, dyspnea, a bounding pulse, and an increase in blood pressure.

A nurse is planning to administer multiple medications to a client who has an enteral tube feeding. Which of the following actions should the nurse plan to take?

D. Flush the tube with 15 mL of sterile water. The nurse should flush the feeding tube with 15 to 30 mL of sterile water before administration and between each medication. The nurse should flush the feeding tube with 30 to 60 mL of sterile water following the

A nurse is planning teaching to a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to the learning?

D. Practice sessions Practice sessions require psychomotor skills when learning.

A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as a potential indication of elder abuse?

D. The caregiver insists on remaining in the room. A caregiver who refuses to leave the room during an admission assessment can be an indication of potential mistreatment of the client who is receiving care. The nurse should evaluate the client for additional signs of potential mistreatment throughout the admission assessment.

A nurse is preparing to administer 0.5 mL of oral single dose liquid medication to a client. Which of the following actions should the nurse take?

Gently shake the container of medication prior to administration

A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching?

Have family members wear a gown and gloves when visiting. ,Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the transmission of Clostridium difficile spores. Staff must also wear gowns and gloves.

A nurse is caring for a client who is receiving 24 hour urine collection. Which of the following statements by the client indicates an understanding of the teaching?

I flushed what I urinated at 7:00 am and have saved all urine since

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice?

Initiate an enteral feeding through a gastrostomy tube .It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes.

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure.

Inject air into NPH insulin Inject air into regular insulin Withdraw regular insulin Withdraw NPH insulin

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?

Tell the client to keep the head of the bed elevated at least 30 degrees.

A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend?

Walking briskly Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy.

A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the t is experiencing spiritual distress?

What could I have done to deserve this illness

A nurse in a clinic is caring for a middle adult client who states, "the doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make?

You should have a fecal occult blood test every year

a nurse is preparing to delegate client care tasks to an assistive personnel. which of the following tasks should the nurse delegate?

ambulating a client who is postoperative

a nurse is caring for a client who has decreased mobility. which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures?

apply an ankle-foot orthotic device to the client's feet

A nurse is preparing to transfer a client who can bear weight in one leg from the bed to the chair. After securing a safe environment, which of the following actions should the nurse take next?

assess the client for orthostatic hypotension

A nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?

breathing sounds When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to provide is the current status of the client's breath sounds.

A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long term care facility. Which of the following documentation should the nurse include?

current medications

A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?

evacuate the client

a nurse is caring for a client who reports difficulty falling asleep. which of the following recommendations should the nurse make?

maintain a consistent time to wake up each day

medical history client is receiving chemotherapy for tx of breast cancer Diagnostic Results Week 1:Hct 42% (37% to 47%)Hgb 15 g/dL (12 g/dL to 16 g/dL)WBC count 8,000/mm3 (5,000 to 10,000/mm3)Platelet count 350,000/mm3 (150,000 to 400,000/mm3)Potassium 3.7 mEq/L (3.5 to 5 mEq/L) Week 2:Hct 37% (37% to 47%)Hgb 12 g/dL (12 g/dL to 16 g/dL)WBC count 6,000/mm3 (5,000 to 10,000/mm3)Platelet count 100,000/mm3 (150,000 to 400,000/mm3)Potassium 3.6 mEq/L (3.5 to 5 mEq/L)

the client is at risk for bleeding as evidenced by the clients platelet count

a charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. which of the following actions by the newly licensed nurse requires intervention by the charge nurse?

the newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field .The newly licensed nurse should place the cap with the sterile side up on a clean surface because the outer edges are unsterile and will contaminate the sterile field. The edges of the sterile field are considered contaminated. Therefore, the nurse should place all sterile items inside the 2.5 cm (1 inch) border of the field

A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

when descending stairs, I will first shift my weight to my right leg.

Nurses' Notes 1000:Client reports sore throat, productive cough with yellow-colored mucus, and fever for the past 3 days. Client has swollen lymph nodes. Client also reports headache that, "won't go away." Client's face is flushed and diaphoretic. Throat culture and blood work obtained as prescribed. Vital Signs 1000:Blood pressure 132/68 mm Heart rate 99/min Respiratory rate 20/min Temperature 38.3° C (101° F) Oxygen saturation 96% on room air Diagnostic Results 1100:Positive throat culture for streptococci bacteria.

which of the following actions should the nurse take? SATA initiate droplet precautions wear a mask w/in 1m of the client request a prescription for an antibiotic medication apply a mask on the client when they leave their room