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 caring for a client on a medical-surgical unit.

Which of the following actions are part of the isolation precautions for this client?

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 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 documenting client care. Which of the following abbreviations should the nurse use?

A nurse is preparing to administer several medications via NG tube to a client who is receiving a continuous tube feeding. Which of the following actions should the nurse take?

A nurse is performing postural drainage with percussion and vibration for a client who has cystic fibrosis. Which of the following actions should the nurse take?

A nurse is preparing to insert an IV catheter for a client following a right mastectomy. Which of the following veins should the nurse select when initiating IV therapy?

A nurse is planning care for a client who is concerned about her tobacco smoking habits and is in the contemplation stage of health behavior change. Which of the following actions should the nurse plan to take during this stage?

A nurse is providing teaching to a client who has a newly prescribed hearing aid. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who has tuberculosis. Which of the following precautions should the nurse plan to implement when working with the client?