A nurse is assisting in the care of a client.

Exhibits

Complete the following sentence:

At 1000 the nurse enters the client's room. The first action the nurse should take is

dropdown

followed by

dropdown

A nurse is collecting data from an older adult client who lives alone. Which of the following findings should the nurse identify as the priority?

A nurse is providing end-of-life care to a client who is experiencing dyspnea. Which of the following actions should the nurse take?

A nurse is assisting in the care of a client who is receiving newly prescribed IV antibiotics.
Which of the following findings should the nurse report immediately?

A nurse is assisting in the care of a client.

Complete the following sentence:

At 1000 the nurse enters the client's room. The first action the nurse should take is

A nurse on a medical-surgical unit is caring for a postoperative client who reports difficulty sleeping due to noise. Which of the following interventions is appropriate for the nurse to implement?

A nurse is assisting in the care of a client.

Nurses' Notes

Day 1:

The client is receiving intermittent tube feedings via a nasogastric tube.

Abdomen is soft, nondistended.

Head of client's bed is positioned to 30° pH of gastric aspirate 4.0

Gastric residual volume is 50 mL Day 2:

Abdomen is distended. Client reports nausea and is coughing.

Gastric residual volume 550 mL pH of gastric aspirate 4.5

Nurses' Notes

Day 2:

Abdomen is distended. Client reports nausea and is coughing Gastric residual volume 550 mL

pH of gastric aspirate 4.5 Vital Signs

Day 2:

Temperature 37° C (98.6° F) Blood pressure 114/68 mm Hg Heart rate 110/min Respiratory rate 24/min

Pulse oximetry 90% on room air

Select the findings in the client's medical record that require further action by the nurse. To deselect a finding, click on the finding again.

Choices

Nurses' Notes Day 2:

Abdomen is distended. Client reports nausea and is coughing

Gastric residual volume 550 mL pH of gastric aspirate 4.5

Vital Signs

Day 2:

Temperature 37° C (98.6° F) Blood pressure 114/68 mm Hg Heart rate 110/min Respiratory rate 24/min

Pulse oximetry 90% on room air

A nurse is collecting data from a client who is immobile and has a potential deep-vein thrombosis. Which of the following findings should the nurse report to the provider?

A home health nurse is assisting in the care of a client.

Nurses' Notes Day 1:

Collecting client data on food safety.

Raw meats and raw vegetables are prepared together on one cutting board. Refrigerator is set to 6.7° C (44° F)

Leftovers are discarded after 7 days in refrigerator. Frozen foods are defrosted on the countertop.

Client washes hands for 10 seconds before cooking.

Leftovers are refrigerated after sitting on the countertop for 3 hr.

Reinforced client teaching about food safety. Follow-up visit scheduled in 2 weeks.

Day 14:

At client's home to collect follow-up data on food safety. Uses one cutting board to prepare raw meats and a different cutting board to prepare raw vegetables.

The refrigerator is set to 5.6° C (42° F).

Leftovers are discarded after 2 days in refrigerator. Frozen foods are defrosted in the refrigerator.

Client washes hands for 15 seconds before cooking.

Select the 4 findings that indicate an understanding of the reinforced teaching.

A nurse at a long-term care facility is caring for an older adult client who has dementia and is at risk for malnutrition. Which of the following actions should the nurse take to promote an increase in food intake?

A nurse is preparing to set up a sterile field to change a sterile dressing on a client's
abdominal wound. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)