A nurse is caring for a client.

Nurses Notes: Day 1: Custom Nursing Assessment.

Vital Signs: Diagnostic Results: Client is admitted with a 2-day history of headache, muscle aches, fever, sore throat, and fatigue.

Prepare to administer an antibiotic to the client.

Which of the following actions should the nurse take? (Select all that apply.)

A nurse is caring for a client with a tracheostomy. The client’s partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client’s discharge?

A nurse is caring for a 75-year-old male client who is experiencing difficulty breathing and shortness of breath.

The nurse is caring for the client following a thoracentesis.

(Select the 3 findings that require immediate follow-up.)

A nurse on a cardiac care unit is caring for a preschooler.

Hospital Day 1, 17:38:

Medication Administration Record.

20:15:

Received 4-year-old child with an exacerbation of heart failure.

Family reports history of congenital mitral stenosis.

Breath sounds with wheezing noted in bilateral lower lobes.

Nonproductive cough noted.

Dyspnea with respiratory rate 30/min.

Oxygen at 2 L/min applied per nasal cannula.

Telemetry applied:

Sinus rhythm at rate 116/min.

Abdomen soft, nontender.

Bowel sounds positive in all 4 quadrants.

Lower extremities with 2+ edema noted.

Pedal pulses palpable bilaterally.

Peripheral saline lock intact to right forearm with no signs and symptoms of infection.

Weight 26 kg (44 lb).

Increase in dyspnea noted with orthopnea.

Nasal flaring with respiratory rate of 36/min. Lung sounds with wheezing noted throughout.

Lower extremity edema 3+ to bilateral lower extremities.

Extremities cool with decreased skin pigmentation noted.

Peripheral pulses weak bilaterally.

Jugular vein distention noted.

Provider notified.

Received prescription for additional dose of furosemide.

The client is at risk for developing:

A nurse is caring for a school-age child who has leukemia.

Which of the following assessment findings should the nurse report to the provider? Select the 6 findings that should be reported to the provider.

A nurse is caring for a client who was recently admitted and has symptomatic bradycardia. Temperature: 36.6°C (97.8°F). Apical pulse: 42/min.

Respiratory rate: 26/min.

Blood pressure: 104/68 mm Hg. Oxygen saturation: 94% on room air. Complete the following sentence by using the list of options.

The nurse is caring for the client immediately following the insertion of the permanent pacemaker.

The nurse should monitor the client for:

A nurse is caring for a client who is 12 hours postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations?

A nurse is providing teaching to a client who has neutropenia. Which of the following information should the nurse include in the teaching?

A nurse is educating clients about breast cancer at a community health event. Which of the following statements should the nurse include in the training?

A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client?

A nurse is caring for a client who has chronic renal disease and is receiving therapy with epoetin alfa. Which of the following laboratory results should the nurse review for an indication of a therapeutic effect of the medication?