A nurse is caring for a client who has a spinal cord injury.

Nurses' Notes 0600:

Adventitious lung sounds auscultated in lower lobes bilaterally. Spirometry encouraged. Cough productive for clear sputum.

1000:

Cough productive for clear sputum following incentive spirometry and coughing exercises. Face and neck flushed. Client reports headache.

Abdomen distended. Last bowel movement was 2 days ago with hard stool. Provider Prescriptions

Nifedipine 30 mg PO for blood pressure greater than 150/100 mm Hg and notify provider Acetaminophen 650 mg PO q4 hr PRN pain

For each potential nursing action, click to specify if the action is anticipated or contraindicated for the client.

The nurse continues to care for the client.

Highlight the findings that indicate improvement in the client's condition. To deselect a finding

A case manager is meeting with a client who asks about using alternative therapies to manage her rheumatoid arthritis. Which of the following statements should the nurse make?

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?

A nurse has identified tasks to delegate to a group of assistive personnel (AP) after receiving change-of-shift report. Identify the sequence of steps the nurse should follow when delegating tasks to the APs. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

A nurse is preparing to administer a medication that is available in a glass ampule. Which of the following actions should the nurse plan to take?

A nurse is teaching a class about providing care within the legal scope of practice to a group of nurses.
The nurse should include that which of the following procedures is outside the legal scope of practice for an RN?

A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy to obtain a copy of the therapist's notes. Which of the following responses should the nurse make?

A nurse is reviewing the medical records of four clients. The nurse should identify which of the following client findings that requires follow-up care.

A nurse is caring for a client who has been admitted to the antepartum unit.

History and Physical Day 1,0900:

30-year-old client at 33 weeks gestation, Gravida 4 Para 3 Maternal blood type: Rh+

Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks gestation. Nurses' Notes

Day 1, 0900:

Client reports lower back pain and pinkish vaginal discharge.

Uterine contractions every 8 minutes, palpate strong, duration 30 seconds. FHR baseline 145, minimal variability.

Cervical exam indicates 2 cm, 50% effaced, 0 station. Membranes intact.

CBC and urinalysis collected and sent to lab.

Highlight the findings that require follow-up.

A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)