A nurse is caring for a client.

Exhibits

Complete the following sentence by using the lists of options.

The nurse understands that the patient has likely developed

______

and will need to be monitored for

_________

.

A nurse is preparing a client for transfer to a long-term rehabilitation facility following a below-knee amputation of the right leg. Which of the following actions should the nurse take to protect the client's confidentiality?

A nurse is caring for a neonate in the neonatal intensive care unit.

Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

Nurses' Notes

1200:

The neonate is 3 days old. Lung sounds clear to auscultation. Frequent episodes of apnea, responds to tactile stimuli. Oxygen saturation 95% to 98% via nasal cannula. Neonate on radiant warmer.

Temperature 36.3° C (97.3° F)

Heart rate 158/min

Respiratory rate 70/min

Substernal retractions and nasal flaring noted. Orogastric (OG) tube placement verified. Continuous breast milk feedings via OG tube initiated 12 hr ago. The umbilical arterial catheter (UAC) site is clean, dry, and intact. Peripheral pulses 2+. Capillary refill brisk. Abdomen is soft, bowel sounds are present. Abdominal circumference increased by 1 cm (0.4 in) since the prior assessment.

A nurse is planning care for a group of clients and is working with one licensed practical nurse (LPN) and one assistive personnel (AP). Which of the following actions should the nurse take first to manage her time effectively?

A community health nurse is working with a family that is struggling to adapt following the loss of a family member. Which of the following actions should the nurse take first?

A nurse is caring for a client who is receiving radiation therapy and is experiencing anorexia. Which of the following actions should the nurse take?

A nurse is caring for a client who is alert and oriented and is receiving continuous ECG monitoring. The cardiac rhythm strip shows a wavy baseline, no distinguishable P waves, and an increased heart rate. The nurse should identify the cardiac rhythm as which of the following?

A nurse is caring for a client.

Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

Nurses' Notes

0900:

Client who is at 38 weeks of gestation presents to the antepartum unit with uterine contractions, dark red vaginal bleeding, and abdominal pain that started approximately 45 min prior to arrival. Rates abdominal pain a 7 on a scale of 0 to 10. Client reports, "My blood pressure has been high during the pregnancy."

Home Medications: prenatal multivitamin, methyldopa 250 mg PO twice daily Physical Exam:

General: tearful, anxious

Cardiovascular: S1, S2, no murmur

Respiratory: bilateral breath sounds clear

Abdomen: Uterine hypertonicity with a board-like abdomen, tenderness noted upon palpation of left upper quadrant

FHR: 116/min, minimal variability noted

The nurse is continuing to care for the client.

A nurse is evaluating the client's response to therapy. Which of the following recent findings indicate the client's condition has improved or not changed? For each assessment finding, click to specify if the finding indicates that the client's condition has improved or has not changed.

A nurse is caring for a client who experienced a traumatic brain injury 72 hr ago. Which in the client's findings are potential indication of increased intracranial pressure?

A home care nurse is making a follow-up visit with a client who has COPD and is using a compressed oxygen system in his home. Which of the following actions should the nurse take?