A nurse is caring for a client who has bulimia nervosa. Which of the following actions should the nurse take first?

A nurse is contributing to the plan of care for a client who had prolonged exposure to cold weather and has a core body temperature of 32.5°C (90.5° F). Which of the following data is the priority for the nurse to monitor?

A nurse is providing discharge teaching for a client who has a new implantable cardioverter defibrillator (ICD). Which of the following client statements demonstrates understanding of the teaching?

A nurse is assessing the peripheral catheter insertion site of a client who is receiving an infusion. The nurse notices redness and warmth to the touch around the insertion site. The nurse should document the finding as which of the following complications?

A nurse is caring for a client who has bulimia nervosa. Which of the following actions should the nurse take first?

A nurse is assisting with a prenatal examination of a client who is at 8 weeks of gestation.The nurse notes that the client's vagina and vulva are a purplish color. The nurse should document this finding as which of the following?

A nurse is reinforcing discharge teaching with the family of an older adult client about safety precautions when administering a hypotonic enema to the client. Which of the following instructions should the nurse include in the teaching?

A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect?

A nurse in an inpatient mental health facility is reinforcing teaching with a client who signed a consent form for electroconvulsive therapy. Which of the following statements by the clientindicates an understanding of the procedure?

A nurse is assisting with the care of a client.

Nurses' Notes

1000

Client states, "I am tired of undergoing treatment because it doesn't seem to be working." Client states, "I hope I am just constipated." Appendectomy scar on right lower quadrant. Abdomen is soft, tender in right lower quadrant, bowel sounds present in all four quadrants.

1200

Surgeon has notified the client that surgical removal of the mass is advisable due to the client's history of metastasis and ongoing treatment failure. The client and their partner want to discuss end-of-life care. Client states, "I am unsure what it means to have a living will or a do-notresuscitate order." The client's partner states, " don't understand what power of attorney means. Both client and partner indicate that they might wish to decline further treatment as well as further fesaving measures should they become necessary. The partner states "How can we be sure that our decision about care will be honored?"

Select the 4 responsibilities the nurse has in relation to the client's advance directives.

A nurse is caring for a client receiving mechanical ventilation via an endotracheal (ET) tube. The high-pressure alarm is beeping, and the client is experiencing respiratory distress. The nurse is unable to determine the cause of the alarm. Which of the following actions should the nurse take?