A nurse is caring for a client in active labor.

Exhibits

The nurse is assuming care for the client at 0305. For each nursing action, click to specify if the nursing action is essential or contraindicated for the client.

A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar disorder. The partner states, “I don't know what to do. Everything has been happening so quickly.” Which of the following responses by the nurse is therapeutic?

A nurse is creating a plan of care for a client who has paranoid personality disorder and refuses to take their medication. Which of the following interventions should the nurse include in the plan?

A nurse in an emergency department is planning care for a client who has abdominal trauma from a motor-vehicle crash. Which of the following provider prescriptions should the nurse implement first?

A nurse is caring for a client who is newly diagnosed with diabetes mellitus and is prescribed an 1800 calorie ADA diet. The client is refusing to eat the provided meals. Which of the following actions should the nurse take?

A nurse is assessing a child who is being treated for bacterial pneumonia. The nurse notes an increase in the child’s blood glucose. The nurse should identify this finding as an adverse effect of which of the following medication?

A nurse is caring for a client who is receiving IV fluid therapy. For which of the following findings should the nurse monitor as an adverse effect of the IV fluid therapy?

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

Nurses' Notes

1400:

Upon admission assessment, client is lying in the fetal position. Client reports abdominal pain as a 10 on a 0 to 10 scale and radiating to right shoulder. Abdomen is distended and rigid. During assessment, client vomited moderate amount bright red emesis.

Vital Signs

1400:

Temperature 36.5° C (97.7" F)

Heart rate 120/min

Respiratory rate 20/min

Blood pressure 70/49 mm Hg

SpO2 95% room air

A nurse in labor and delivery is caring for a client who is at 30 weeks of gestation.

Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

The client is at risk for developing

A nurse is caring for a client who is receiving enteral feedings via a nasogastric tube. Which of the following conditions places the client at risk for aspiration?

A nurse is caring for a child who reports migraine headaches for the past 4 months. Which of the following actions should the nurse take first?