A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?

A nurse on a medical-surgical unit is caring for a postoperative client who reports difficulty sleeping due to noise. Which of the following interventions is appropriate for the nurse to implement?

A nurse is observing an assistive personnel (AP) provide postmortem care for a client prior to visitation by their loved ones. Which of the following actions by the AP requires intervention by the nurse?

A nurse is assisting in the care of a client.

Nurses' Notes

Day 1:

The client is receiving intermittent tube feedings via a nasogastric tube.

Abdomen is soft, nondistended.

Head of client's bed is positioned to 30° pH of gastric aspirate 4.0

Gastric residual volume is 50 mL Day 2:

Abdomen is distended. Client reports nausea and is coughing.

Gastric residual volume 550 mL pH of gastric aspirate 4.5

Nurses' Notes

Day 2:

Abdomen is distended. Client reports nausea and is coughing Gastric residual volume 550 mL

pH of gastric aspirate 4.5 Vital Signs

Day 2:

Temperature 37° C (98.6° F) Blood pressure 114/68 mm Hg Heart rate 110/min Respiratory rate 24/min

Pulse oximetry 90% on room air

Select the findings in the client's medical record that require further action by the nurse. To deselect a finding, click on the finding again.

Choices

Nurses' Notes Day 2:

Abdomen is distended. Client reports nausea and is coughing

Gastric residual volume 550 mL pH of gastric aspirate 4.5

Vital Signs

Day 2:

Temperature 37° C (98.6° F) Blood pressure 114/68 mm Hg Heart rate 110/min Respiratory rate 24/min

Pulse oximetry 90% on room air

A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality. In which of the following situations can the nurse disclose health information without the client's written consent?

A nurse is caring for a client who has a new prescription for a belt restraint. Which of the following actions should the nurse take?

A nurse is collecting data from an older adult client who lives alone. Which of the following findings should the nurse identify as the priority?

A nurse is caring for a client who is postoperative.

Medication Administration Record

0830:

Morphine 10 mg subcutaneous every 3 hr PRN pain

What documentation in the client's medical record requires further action by the nurse.

A home health nurse is assisting in the care of a client.

Nurses' Notes Day 1:

Collecting client data on food safety.

Raw meats and raw vegetables are prepared together on one cutting board. Refrigerator is set to 6.7° C (44° F)

Leftovers are discarded after 7 days in refrigerator. Frozen foods are defrosted on the countertop.

Client washes hands for 10 seconds before cooking.

Leftovers are refrigerated after sitting on the countertop for 3 hr.

Reinforced client teaching about food safety. Follow-up visit scheduled in 2 weeks.

Day 14:

At client's home to collect follow-up data on food safety. Uses one cutting board to prepare raw meats and a different cutting board to prepare raw vegetables.

The refrigerator is set to 5.6° C (42° F).

Leftovers are discarded after 2 days in refrigerator. Frozen foods are defrosted in the refrigerator.

Client washes hands for 15 seconds before cooking.

Select the 4 findings that indicate an understanding of the reinforced teaching.

A nurse in a provider's office is collecting data from an older adult client. The client states that he is having difficulty sleeping. Which of the following strategies should the nurse recommend to promote sleep?

A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?