A nurse is admitting a client who reports tightness in their chest that radiates to left arm.

Exhibits

The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up.

A nurse is planning care for a client who has hemiplegia. Which of the following interventions should the nurse include?

A nurse is assessing a client who is postoperative following a transurethral resection of the prostate and is receiving continuous bladder irrigation. The client reports bladder spasms, and the nurse notes a scant amount of fluid in the urinary drainage bag. Which of the following actions should the nurse take?

A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg. a fluid intake of 960 mL, and an output of 300 mL in the past 12 hr. Which of the following actions should the nurse take?

A nurse is admitting a client who reports tightness in their chest that radiates to left arm.

Click to highlight the findings below that would indicate that the client has a potential problem. To deselect a finding, click on the finding again.

Nurses' Notes

1000:

Client reports tightness in chest that radiates to left arm. States pain as 7 on a scale of 0 to 10. Started to feel nauseous after breakfast. Client states, "I had scrambled eggs and bacon like I do every morning." Client is diaphoretic and short of breath. Heart rate irregular and tachycardic. Alert and oriented to person, place, and time. Lungs clear to auscultation in all lobes. Bowel sounds are present in all 4 quadrants. +1 pedal pulses. Skin is cool to touch. Capillary refill less than 2 seconds.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following nursing actions are appropriate? (Select all that apply.)

A nurse is caring for a client who is 2 days postoperative following a below-the-knee amputation and asks about the purpose of maintaining an elastic bandage around the residual limb of the extremity. Which of the following is an appropriate response by the nurse?

A nurse is assessing a client who has a urinary catheter. The nurse notes the client's IV tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse should identify that the client is at risk for which of the following conditions?

A nurse is caring for a client.

A nurse is reviewing the client's medical record. After reviewing the medical record, which of the following actions should the nurse plan to take? For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Potential Prescription: Anticipated /Nonessential /Contraindicated

A nurse is preparing to administer fresh frozen plasma to a client. Which of the following actions should the nurse take?

A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft?