A nurse is caring for a client who has schizophrenia and is taking an antipsychotic medication. Which of the following screening tools should the nurse use to identify tardive dyskinesia?

A nurse is reinforcing teaching about hand hygiene with a newly licensed nurse. Which of the following information should the nurse include in the teaching?

A nurse is reinforcing teaching with the support person of a client who is in the first stage of labor. Which of the following instructions should the nurse include regarding effleurage?

A nurse is giving an intramuscular injection to a newborn who was delivered at 38 weeks of gestation. Which of the following pain scales should the nurse use to assess the newborn's pain?

A nurse is reinforcing teaching about home infection prevention with a client who is HIV positive. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who is in a coma and is scheduled for a surgical procedure. Which of the following actions should the nurse take?

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 contributing to the plan of care for a client who has ascites due to cirrhosis. Which of the following interventions should the nurse recommend to include in the plan?

A nurse is collecting data from a client who has a long leg cast on his left leg. Which of the following findings is the priority?

A nurse is preparing to provide tracheostomy care for a client.

Which of the following actions should the nurse plan to take?

A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?