A nurse is admitting an adolescent who has rubella.

Which of the following actions should the nurse take?

A nurse is providing care for a client who experienced a myocardial infarction prior to a cardiac arrest. Which of the following laboratory tests will identify early injury to the cardiac muscle?

A staff nurse is observing a newly licensed nurse suction a client’s tracheostomy.

Which of the following actions by the newly licensed nurse requires intervention by the staff nurse?

A nurse is caring for a client in a clinic.

Exhibit 1 Exhibit 2.

Nurses' Notes.

0900:

A16-year-old client reports to the clinic with their caregiver. The client's caregiver informs the nurse that the client has "not been themselves lately." The client's parents and a sibling passed away from injuries sustained when a tornado moved through their town 1 month ago. They were the only survivor and witnessed their family's deaths.

0910:.

Client appears anxious but answers questions appropriately for age. They report experiencing nightmares that awaken them at night and startle easily during thunderstorm, but the client admits that they have always been afraid of thunderstorms. Client admits smoking marijuana for about 1 month because it helps clear their mind. They also admit that they have no desire to leave the house. They do attend school regularly and are on the honor roll.

Vital Signs.

0915:

Temperature 36.7° C (98° F).

BP 122/80 mm Hg Respiratory rate 20/min Heart rate 99/min.

Based on the information in the client's medical record, which of the following findings require immediate follow-up?

Select the 4 findings that require follow-up.

A nurse is caring for a client who received 50,000 units of IV heparin rather than the prescribed 5,000 units. Which of the following actions should the nurse take first?

A nurse is assessing a client who has preeclampsia and is receiving magnesium sulphate via continuous IV infusion. For which of the following therapeutic effects should the nurse monitor the client for?

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

The nurse is preparing to discharge the client. Which of the following statements by the client indicate an understanding of the discharge teaching?

Select all that apply.

A nurse is assessing a client who is taking haloperidol and is experiencing pseudoparkinsonism.

Which of the following findings should the nurse document as a manifestation of pseudoparkinsonism?

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 is caring for a client who is experiencing expressive aphasia and right hemiparesis following a stroke.

Which of the following actions by the nurse best promotes communication among staff caring for the client?

A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching as an example of malpractice?