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A nurse is caring for a client who reports using several herbal medicines. Which of the following actions should the nurse take?
B. Verify the herbal supplements do not interact with medications the provider has prescribed
Use the pain scale to determine the client's pain level A nurse is using the I-SBAR communication tool to give a client's provider information about the client. The nurse should convey this client's pain status in which portion of the report?
A. Assessment
A nurse is admitting a client who has decreased circulation in his left leg. which of the following actions should the nurse take first?
A. Evaluate pedal pulses
A nurse is assessing a client who is unconscious. family members are present and answer the nurse's questions about the client's medical history. the nurse should document this information as which of the following types of data
A. Secondary-source data
A nurse is planning to administer pain medication to a client following abdominal surgery. Which of the following actions should the nurse take first?
A. Use the pain scale to determine the client's pain level
A nurse on an oncology unit receives report at the beginning of her shift about 4 clients who are postoperative. Which of the following clients should the nurse see first?
B. A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage
A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of primary prevention?
B. Educating clients about the recommended immunization schedule for adults
A nurse is caring for a client who was transferred to the surgical unit by stretcher from the PACU. Which of the following actions should the nurse perform immediately following the transfer?
B. Check the client's vital signs
A nurse is measuring a client's vital signs. the clients resting radial pulse rate is 55/min. which of the following actions should the nurse take next?
B. Measure the client's apical pulse rate.
A nurse in a provider's clinic is taking a client's age, height, weight, and vital signs. The nurse should identify this action as part of which of the following components of the nursing process?
C. Assessment
A nurse is measuring a client's vital signs and notices an irregularity in the pulse. Which of the following actions should the nurse take?
C. Count the apical pulse rate for 1 full min and describe the rhythm in the chart
A nurse is assessing a client's peripheral pulses. which of the following descriptions should the nurse use to document the findings
C. Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities.
A nurse is measuring a client's vital signs. The client's heart rate is 105/min. The nurse should document this finding as which of the following alterations?
C. Tachycardia
A nurse is taking a client's vital signs. Which of the following findings should the nurse identify as outside the expected reference range?
D. BP 145/90 mmHg
A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals, and the readings are inconsistent. Which of the following actions should the nurse take
D. Disconnect the machine and measure the blood pressure manually every 15 min
A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and may have a right ear infection. Which of the following routes should the nurse use to obtain the child's temperature?
D. Temporal
