A nurse is assessing a client who received 2 units of packed RBCs 48 hr ago. Which of the following findings should indicate to the nurse that the therapy has been effective?

A nurse at a mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is using dissociation as a defense mechanism?

A nurse is assisting in the care of an older adult client who was admitted from a long-term care facility.

Admission Assessment 1400:

Client's history includes cigarette smoking for 50 years but quit 3 years ago, Parkinson's disease, and anxiety. Yesterday, client reported "feeling bad." Client is alert and oriented to self, reports upper chest discomfort, and is coughing up thick clear sputum.

Select the 3 findings that require immediate follow-up.

A nurse is performing an admission assessment on a client who had a recent positive pregnancy test. The first day of her last menstrual period (LMP) was May 8. According to Nägele's rule, which of the following dates should the nurse document as the client's estimated date of birth (EDB)?

A nurse is caring for an adolescent.

Admission Assessment 1400:

• Adolescent brought to emergency department by parents following a fall while skateboarding.
• Adolescent reports pain in their right leg as 10 on a scale of 0 to 10 and is unable to bear weight.
• Adolescent is awake, alert, and oriented x 3.
• Lungs clear, respirations even and regular.
• S1 and S2 with regular rate and rhythm.
• Abdomen soft and nontender with active bowel sounds in all four quadrants.
• Right lower extremity with open wound and displaced bone.
• Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds.

Select the 4 findings that require follow-up.

A nurse is planning care for a client who is receiving chemotherapy and has neutropenia.

Which of the following interventions should the nurse include in the plan?

A nurse is caring for a client who has deep-vein thrombosis and a new prescription for antiembolitic stockings.
Which of the following actions should the nurse take?

A nurse is caring for a client who is 1 hr postpartum.

Nurses' Notes 1200:

Large amount of lochia rubra noted on perineal pad. Fundus boggy at two fingerbreadths above the umbilicus. Oxytocin 20 units being administered via continuous JV infusion.

1215:

Large amount of lochia rubra with several large clots noted. Client reports feeling anxious. Skin cool and clammy. Provider notified.

Select the 6 actions the nurse should take.

A nurse is planning to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

A nurse is providing discharge teaching to a client who is to receive home oxygen therapy.

Which of the following instructions should the nurse include in the teaching?