A nurse is caring for a 9-year-old child at a clinic.

Vital Signs.

1000:. Temperature 36.8°C (98.2 °F). Heart rate 102/min.

Respiratory rate 22/min.

BP 100/60 mm Hg. Oxygen saturation is 98% on room air.

Nurses' Notes.

1000:.The child has been brought to the clinic by their parent due to a. report of right arm pain.

The parent states that several hours.

ago the child tripped and fell onto the sidewalk while playing.

outside.

The child states, "I was running when we were playing,and I tripped over a curb." The child is supporting their arm across.

their body.

Assessment.

1000:The child is alert and appears developmentally appropriate for their.

age and well nourished.

Respirations are easy and unlabored.

Abdomen nondistended.

The right forearm and fingers are edematous.

Ecchymotic area.

noted on the outer aspect of the forearm.

Radial pulse +2. Fingers.

slightly cool to the touch.

A child can move fingers and reports a mild.

"tingling" sensation.

The child verbalizes a pain level of 4 on a scale.

of 0 to 10. Abrasion noted on the right knee.

No active bleeding.

Multiple areas of bruising were noted on the lower extremities in various.

stages of healing.

The nurse should determine that the assessment findings are consistent with.

which of the following conditions? For each potential condition, click to specify if the assessment findings are.

consistent with a sprain, a fracture, or dislocation.

Each finding may support this.

more than 1 condition.

A nurse is caring for a newborn.

Vital Signs.

0640:. Temperature 36.7°C (98.1° F) axillary.

Heart rate 154/min.

Respiratory rate 68/min.

BP 72/48 mm Hg. 0650:. Heart rate 156/min.

Respiratory rate 72/min.

0700:. Temperature 37° C (98.6° F) axillary.

Heart rate 156/min.

Respiratory rate 76/min.

Admission Assessment.

0630:. Newborn delivered via cesarean birth under spinal anesthesia at. 0630.

Amniotic fluid clear.

0631:. 1-min Apgar score 7. 0636:. 5-min Apgar score 9. Newborn transferred to nursery.

Nurses' Notes.

0640:. Weight 4200 gm (9 Ib 4 oz), head circumference 35.5 cm (14 in). Respiratory rate 68/min, with mild grunting.

0650:. Respiratory rate 72/min, with mild grunting.

0700:. Respiratory rate 76/min, with moderate grunting and mild.

intercostal retractions.

Drag words from the choices below to fill in each blank in the following.

sentence.

The client is at risk for developing Target 1 and Target 2.

A nurse is caring for a client in active labor.

Admission Assessment.

0200:. Gravida 1, Para 0 at 39 weeks gestation.

Presents with.

contractions occurring every 5 to 6 min, 45 to 60 seconds.

duration.

Cervical examination 4 cm dilated, 50% effaced.

Admit.

to the labor and delivery unit.

Nurses' Notes.

0200:. Admitted to the labor and delivery unit, and reports pain as 7 on a scale.

of O to 10 with contractions.

Cervix 4 cm dilated, 50% effaced,with membranes intact.

0230:. The client reports increasing discomfort with contractions.

Cervix 5. cm dilated, 60% effaced, with membranes intact.

Contractions.

occurring every 5 min, 45 to 60 seconds duration.

0300:. Epidural anesthesia was initiated.

Cervix 7 cm dilated, 70% effaced,. with membranes intact.

Contractions occur every 4 to 5 min,60 seconds duration.

Vital Signs.

0200:. Temperature 36.9° C (98.4° F). Heart rate 86/min.

Respiratory rate 18/min.

BP 118/78 mm Hg. 0230:. Temperature 37° C (98.6° F). Heart rate 88/min.

Respiratory rate 20/min.

BP 120/80 mm Hg. 0300:. Temperature 37.1° C (98.8° F). Heart rate 90/min.

Respiratory rate 18/min.

BP 122/76 mm Hg. The nurse is assuming care for the client at 0305.

For each nursing action, click to specify if the nursing action is essential. contraindicated for the client.

An older client with a history of heart failure is admitted with influenza and requests assistance to sit up in bed to eat lunch. The nurse observes the unlicensed assistive personnel (UAP) wearing a gown and gloves to assist the client.

Which action should the nurse take?

A nurse receives a telephone call from a client's family member, who asks the nurse for an update on the client's condition.
Which of the following actions should the nurse take to maintain the client's confidentiality?

A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets 20 minutes ago.
The client is lethargic and has a respiratory rate of 10/min.
After securing the client's airway and initiating an IV, which of the following actions should the nurse take next?

A nurse is caring for a client who experienced a traumatic brain injury 72 hr ago.
Which of the following findings should the nurse identify as a potential indication of increased intracranial pressure?

A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community.
In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?