A home health nurse is performing a fall risk assessment for an older adult client. Which of the following findings should the nurse identify as a potential fall risk in the home?

A nurse is caring for a postoperative client. Which of the following findings indicate the client may be actively bleeding?

A nurse is teaching a client about logrolling while in bed. Which of the following information should the nurse include in the teaching?

A home health nurse is caring for a group of older adult clients. Which of the following statements by a client is an indication they may be experiencing social isolation?

A nurse is assessing a client who recently started taking an antibiotic. The nurse should identify that which of the following findings is an indication of a mild allergic reaction?

A nurse is administering a medication to a client. The nurse identifies the client has an allergy to the medication after it has been administered. Which of the following actions should the nurse take?

A nurse is assessing a client's cranial nerve VII. Which of the following responses should the nurse expect?

A nurse is caring for a client who is scheduled for an appendectomy.

Exhibit 1 Exhibit 2 Exhibit 3

Nurses' Notes

1050:

Received handoff report from the ED nurse for a client who has acute appendicitis and is scheduled for an appendectomy. Client reports that pain began in the midabdominal region during the night. This morning the pain intensified and localized to the right lower quadrant region. Pain continues to intensify. rebound tenderness noted. Reports vomiting one time after eating a piece of toast at 0600 with continued feelings of nausea.

Peripheral IV to the left forearm with IV fluids infusing.

1200:

Informed consent obtained by the surgeon performing the procedure. Placed in the client's medical record. Client expressing concern about potential complications that could result from the surgery.

Medical History

1050:

Received influenza vaccine 1 month ago.

Thyroid disease, taking levothyroxine for 14 years. History of cholecystectomy 3 years ago.

Denies alcohol or illegal drug use. Reports smoking approximately 6 cigarettes per day for the past 10 years. Allergic to shellfish, latex, and penicillin.

Vital Signs

0945, Upon admission to emergency department (ED): Temperature 38.3°C(100.9° F)

Pulse rate 102/min Respiratory rate 22/min

Blood pressure 122/80 mm Hg Oxygen saturation 96% on room air Pain reported as 6 on a scale of 0 to 10.

1050, Upon admission to medical-surgical department Temperature 38,4° C (101.2° F)

Pulse rate 104/min Respiratory rate 22/min

Blood pressure 124/80 mm Hg Oxygen saturation 96% on room air Pain reported as 8 on a scale of 0 to 10

The nurse is preparing the client for surgery. Select the 3 findings that require follow-up prior to surgery.

A charge nurse has four new clients arriving on the unit for admission. Which of the following clients should the nurse place in airborne precautions?

A nurse is caring for a client who was recently diagnosed with a terminal illness. The client tells the nurse, "I am looking forward to seeing my grandchildren grow up." The nurse should identify that the client is experiencing which of the following stages of grief?

A nurse is assessing a client's abdomen. In what order should the nurse complete the steps of the assessment? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)