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.

A nurse is caring for a postpartum client in an outpatient setting.

A nurse is caring for a postpartum client in an outpatient setting.

Complete the following sentence by using the lists of options.

The client is at highest risk for developing

A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take?

A nurse is teaching a prenatal class about infection prevention at a community center.
Which of the following statements by a client indicates an understanding of the teaching?

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

Vital Signs Day 1,

0900:

Admission:

Temperature 38.4° C (101.1° F) Heart rate 92/min Respiratory rate 18/min Blood pressure 130/78 mm Hg
Pre-pregnancy BMI 27.6 Current BMI 29.9

The client is at risk for developing which of the following 2 complications? Select 2 complications the client is at risk of developing.

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Vital signs include: heart rate 122 beats/minute, respiratory rate 28 breaths/minute, and blood pressure 170/90 mmHg.

Which assessment finding warrants the most immediate intervention by the nurse?

A nurse is providing discharge teaching to a client who has a new ostomy.
Which of the following instructions should the nurse include?

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 newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse identify as tertiary prevention?

Urine dipstick:
pH 6.0 mg/dl. (4.6 to 8 mg/dL)

Specific Gravity 1.022 (1.010 to 1.025)

Leukocyte esterase negative (Negative)

Nitrite negative (Negative)

Protein trace negative (Negative)

Glucose negative (Negative)

Ketones none (None)

Bilirubin none (None)

Blood none (None)

Which of the following statements should the nurse include in the client's teaching?

Select all that apply.

A nurse is caring for a client who has an indwelling urinary catheter. The nurse notes that sediment is present in the urine. Which of the following actions should the nurse take to obtain a sterile urine specimen?