A nurse is assisting a postoperative client.

The client is alert and oriented to person, place, and time, and reports incisional pain of 9 on a scale of 1 to 10. Morphine 8 mg was administered subcutaneously as prescribed at 0900.

The client is now sleeping and is difficult to arouse.

Pupils are 3 mm, equal and reactive to light.

Temperature is 37.5 C (99.5°), respirations are 10/min, and pulse oximetry is 87% on room air.

Which documentation in the client’s medical record requires further action by the nurse?

A nurse is assisting a postoperative client.

The client is alert and oriented to person, place, and time, and reports incisional pain of 9 on a scale of 1 to 10. Morphine 8 mg was administered subcutaneously as prescribed at 0900.

The client is now sleeping and is difficult to arouse.

Pupils are 3 mm, equal and reactive to light.

Temperature is 37.5 C (99.5°), respirations are 10/min, and pulse oximetry is 87% on room air.

Which documentation in the client’s medical record requires further action by the nurse?

A nurse is assisting in the care of a client who has developed cardiogenic shock.

Which pulse site should the nurse use when assessing circulation to the client’s brain?

A patient is unresponsive to verbal stimuli and exhibits an altered level of consciousness.

Which method should the nurse use to elicit a response from a painful stimulus?

A patient has severe trauma from an automobile accident.

The nurse is checking the gastric pH and is administering Protonix 40 mg IV piggyback two times a day as ordered.

This is prophylactic to prevent which of the following?

A nurse is preparing to administer heparin subcutaneously to a client.

Which action by the nurse is appropriate?

A nurse is attending to a client who has suffered a basal skull fracture.

During the morning hygiene care, the nurse observes a thin clear drainage coming from the client’s right nostril.

What should be the nurse’s immediate action?

Following an explosion at a local chemical lab, several people have sustained burns and are now in the triage area.

Which patient should be attended to first?

A patient with acute pancreatitis is in severe pain.

Which position should the nurse suggest the patient to assume?

A nurse is helping a postoperative patient following a total hip arthroplasty into a supine position.

Which of the following actions is appropriate to prevent hip dislocation?

A nurse is planning care for a client who has a peptic ulcer and a new prescription for sucralfate 2 gm administered twice daily.

When should the nurse plan to administer the medication?