A nurse is assessing a client who is taking digoxin to treat chronic heart failure.
Which of the following findings should indicate to the nurse that the client is developing digoxin toxicity?

A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?

A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include?

A nurse is caring for a client who has been admitted to the antepartum unit.

History and Physical Day 1,0900:

30-year-old client at 33 weeks gestation, Gravida 4 Para 3 Maternal blood type: Rh+

Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks gestation. Nurses' Notes

Day 1, 0900:

Client reports lower back pain and pinkish vaginal discharge.

Uterine contractions every 8 minutes, palpate strong, duration 30 seconds. FHR baseline 145, minimal variability.

Cervical exam indicates 2 cm, 50% effaced, 0 station. Membranes intact.

CBC and urinalysis collected and sent to lab.

Highlight the findings that require follow-up.

A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect?

A nurse is caring for a client in a clinic.

Vital Signs 0915:

Temperature 36.7° C (98° F)

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

Nurses' Notes 0900:

A 16-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 survivors and witnessed their family's deaths.

0910:

The client appears anxious but answers appropriately for age. They report experiencing nightmares that awaken them at night and startle easily during thunderstorms, but the client admits that they have always been afraid of thunderstorms. The client admits to 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 attend school regularly and are on the honor roll.

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

Select the 4 findings that require follow-up.

While performing a routine assessment, a nurse notices fraying on the electrical cord of a client's continuous passive motion (CPM) device. Which of the following actions should the nurse take first?

A nurse is assisting with food selection for a client who follows kosher dietary traditions. Which of the following food choices should the nurse include on the client's food tray?

The nurse reviews the entries in the medical record.

Admission Assessment 0900:
Client reports, "I'm bloated and my stomach hurts." History of prior illness: Client reports a 3-week history of gnawing abdominal pain. Client states, "It's a burning sensation that radiates to my back. I think I've lost a little weight too." Reports one episode of dark, tarry stool. No vomiting. Client reports pain is worse about 1 hr after eating a meal. Past medical history: Osteoarthritis
Social history: Recently divorced, drinks in moderation (3 to 4 drinks per week), smokes tobacco
Current medications:

Ibuprofen 800 mg three times daily PRN arthritis pain Physical Examination:

General: client appears uncomfortable, diaphoretic

Head, ears, eyes, nose, and throat (HEENT): oropharynx clear, mucous membranes moist and pale
Respiratory: bilateral breath sounds clear

Gastrointestinal: epigastric tenderness to palpation, no rebound tenderness or guarding Neurological: oriented x 3 (person, place, and time)

The nurse is ready to begin. For each potential nursing action, specify if the action is indicated or not indicated for the client.
Nursing Actions

A nurse is teaching a new parent about breastfeeding her 2-week-old infant. Which of the following statements by the parent indicates an understanding of the teaching?

A charge nurse is observing a conflict between two nurses who both insist that the charge nurse favors the other when making assignments. Which of the following conflict-resolution strategies should the charge nurse use?