A nurse in a health clinic is caring for a client. Click to highlight the findings that the nurse should report to the provider. To deselect a finding, click on the finding again.

Nurse's Notes

0930:

• Client reports 2-day history of urinary frequency, burning on urination, and lower back and suprapubic pain. States developed a fever of 39.3°C (102.8°F) this morning.
• Oriented x-4, answers questions appropriately.
• S1, S2, on auscultation. Lungs clear on auscultation.
• Bowel sounds x 4 quadrants active, denies nausea or vomiting.

0945:

• Request client provide clean-catch urinary specimen for testing.
• Urinalysis results reviewed.

Vital Signs 0930:

• Temperature: 39.3°C (102.8°F)
• Heart rate: 113/min
• Respiratory rate: 24/min
• Blood pressure: 122/68 mm Hg
• Oxygen saturation: 96% on room air

Diagnostic Results 1030:

Urinalysis

• Appearance: Cloudy
• Color: Amber yellow
• Odor: Aromatic
• pH: 8.0 (Reference: 4.6 to 8.0)
• Protein: 6.5 mg/dL (Reference: 0 to 8 mg/dL)
• Specific gravity: 1.035 (Reference: 1.005 to 1.030)
• Leukocyte esterase: Positive
• Nitrites: Present
• Ketones: None
• Bilirubin: None

A nurse in a walk-in clinic is caring for a client.

Which of the following six findings should the nurse report to the provider? Select the 6 findings that require immediate follow-up.

1300:

• Temperature 39.1° C (102.4° F)
• Heart rate 115/min
• Respiratory rate 30/min
• Blood pressure 99/58 mm Hg
• Oxygen saturation 93% on room air

1330:

• Temperature 39.2° C (102.5° F)
• Heart rate 118/min
• Respiratory rate 28/min
• Blood pressure 91/52 mm Hg
• Oxygen saturation 95% on 2 L/min nasal cannula
• Heart rate
• Skin turgor
• Temperature
• Heart sounds
• Blood pressure
• COVID test results
• Orientation
• Lung sounds

A nurse is assessing a client who has diabetes mellitus prior to performing a blood glucose test. Which of the following findings should indicate to the nurse that the client has hyperglycemia?

A nurse is preparing to perform a physical assessment of a client's abdomen. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A nurse is reviewing the medical record for a newly admitted client. Which of the following laboratory values should the nurse report to the provider?

A nurse is assessing an older adult client. Which of the following findings should the nurse expect?

A nurse is caring for a client who has a prescription for a 250 mL IV fluid bolus. The nurse administers a 500 mL IV bolus. Which of the following actions should the nurse take first?

A nurse is caring for a client who is 2 days postoperative following bowel resection and reports sudden, severe abdominal pain. Which of the following actions should the nurse take first?

A nurse is caring for a client who is receiving continuous enteral feeding via NG tube. Which of the following is an unexpected finding?

A nurse in a health clinic is caring for a client.

Click to highlight the findings that the nurse should report to the provider. To deselect a finding, click on the finding again.

Nurse's Notes and Diagnostic Results

Vital Signs 0930:

• Temperature: 39.3° C (102.8° F)
• Heart rate: 113/min
• Respiratory rate: 24/min
• Blood pressure: 122/68 mm Hg
• Oxygen saturation: 96% on room air

Nurses' Notes 0930:

• Client reports 2-day history of urinary frequency, burning on urination, and lower back and suprapubic pain. States developed a fever this morning.
• Oriented x 4, answers questions appropriately.
• S1, S2 on auscultation. Lungs clear on auscultation.
• Bowel sounds x 4 quadrants active, denies nausea or vomiting.

Diagnostic Results 1030:

• Urinalysis:
  • Appearance: cloudy (clear)
  • Colour: cloudy (amber yellow)
  • Odour: foul (aromatic)
  • pH: 8.0 (4.6 to 8.0)
  • Protein: 6.5 mg/dL (0 to 8 mg/dL)
  • Specific gravity: 1.035 (1.005 to 1.030)
  • Leukocyte esterase: positive
  • Nitrites: present
  • Ketones: none (none)
  • Bilirubin: none (none)
  • Crystals: none (none)
  • Casts: none (none)
  • Glucose: none (none)
  • White blood cells: 8 (0 to 4)
  • Red blood cells: 3 (less than 2)

A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing the client's signature, the client states, "I trust my doctor, but I don't understand what is meant by resecting my intestines." Which of the following actions should the nurse take?