A nurse in an emergency department is reviewing the medical record of a client who is having an acute myocardial infarction.

Which of the following findings places the client at risk if he receives alteplase?

A nurse is caring for a client who has an indwelling urinary catheter.

The nurse notes that sediment is present in the urine.

Which of the following actions should the nurse take to obtain a sterile urine specimen?

A charge nurse is concerned about a recent increase in facility-acquired catheter infections.

Which of the following actions should the nurse take first?

A nurse is verifying a record of informed consent for a client who is scheduled for surgery. Which of the following actions should the nurse take?

A nurse in an emergency department is caring for a client. Nurses' Notes.

1200:.

Client is an 82-year-old male who presents with his adult child for evaluation of right arm pain after a fall. Client noted to have several superficial abrasions on right forearm and elbow. Also has numerous bruises in various stages of healing on arms and upper chest. Client rates pain in right lower forearm an 8 on a 0 to 10 pain scale and is not moving the arm.

1210:.

Client noted to keep head down and makes limited eye contact. Speaks very softly and looks at adult child before answering interview questions. Has strong body odor and clothes are unclean. Client's adult child answers most questions. Client grimacing and guarding right arm.

Client weighed, is 56.2 kg (124 lb) and 175 cm (69 in) tall. BMI 18.3.

1230:.

Client's adult child left facility to go home and get the client’s prescribed medications. Client visibly more relaxed and now speaking more openly to staff with improved eye contact. Client reports that he has lived with his adult child for the past several.

Vital Signs. 1200:.

Temperature 36.7° C (98° F). Heart rate 96/min.

Blood pressure 142/96 mm Hg. Respiratory rate 16/min.

SpO2 97% on room air.

The nurse is preparing to speak to the facility's Social Worker about the client's condition.

Select the 5 findings the nurse should plan to include in the report.

A nurse is admitting a client who has schizophrenia.

The client states, “I’m hearing voices.” Which of the following responses is the priority for the nurse to state?

A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis.

The nurse should monitor the client for which of the following complications?

A nurse is planning care for a client who has a prescription for a bowel-training program following a spinal cord injury.

Which of the following actions should the nurse include in the plan of care?

A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?

A nurse is receiving change-of-shift report for a group of clients.

Which of the following clients should the nurse plan to assess first?

nurse is providing teaching to the parents of a newborn about newborn genetic screening. Which of the following statements should the nurse include in the teaching?