A client at 42-weeks gestation arrives at the labor and delivery unit for a scheduled induction but refuses the prescribed oxytocin infusion because she wants to have a "natural" delivery.

Which action is most important for the nurse to implement?

A client is recovering in the critical care unit following a cardiac catheterization.

Intravenous (IV) nitroglycerin and heparin are infusing.

The client is sedated but responds to verbal instructions.

After changing positions, the client complains of pain at the right groin insertion site.

Which action should the nurse implement?

When performing a focused gastrointestinal system assessment, the practical nurse (PN) asks a male client when his last bowel movement occurred. The client answers, "Three days ago." Which action should the PN implement first?

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound.
Which action should the nurse take next?

A client with delusions tells the nurse, "You aren't doing your job.
Go get those people over there and shoot them before they get me." Which statement is the nurse's best response?

A client tells the nurse about beginning an exercise program a month ago to lose weight and improve sleep.

The client states that it still takes at least two hours to fall asleep at night.

Which action should the nurse implement?

The nurse on the medical-surgical unit is receiving a transfer report from the post-anesthesia care unit (PACU) nurse for a client who had an exploratory laparotomy.

The PACU nurse provides the following information: "1000 mL normal saline is infusing at 125 mL/hr into the left wrist with 600 mL remaining.

Ondansetron 4 mg intravenously every 8 hours is prescribed for nausea.

The last dose was administered at 0700.

The client is currently describing pain at a level 2 on a 0 to 10 pain scale.

The client has a prescription for hydromorphone 1 mg intravenously every 2 hours as needed for pain.

The last dose was administered at 1000." Which additional information should the PACU nurse report?

A nurse is documenting the data collected from an ongoing assessment of a client who has diabetes mellitus.
The nurse writes, “The client reports feeling thirsty and hungry all the time.” How should the nurse label this type of data?

An older male client is admitted with the medical diagnosis of a possible cerebral vascular accident (CVA). He has facial paralysis and cannot move his left side.

When entering the room, the nurse finds the client's wife tearful and trying unsuccessfully to give him a drink of water.

Which action should the nurse take?

A client receives a prescription for 1 liter of lactated Ringer's intravenously (IV) to be infused over 12 hours.

The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only.

If rounding is required, round to the nearest whole number.).

Four days after exposure to the coronavirus (COVID-19), a client has a negative COVID-19 test result.

Eight days after the negative test result, the client presents with fever, fatigue, and cough, and the nurse performs a second COVID-19 test.

Which action is most important for the nurse to take?