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

A nurse is reinforcing teaching with a new mother about facility security measures. Which of the following statements by the mother indicates an understanding of the teaching?

A nurse is assessing a client who is in skeletal traction for a fractured left tibia. The nurse should identify that which of the following findings indicates altered tissue perfusion of the affected extremity?

A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV infusion. Which of the following manifestations should the nurse identify as an adverse effect of the treatment?

A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect?

A nurse is reinforcing teaching with a client who is starting digoxin therapy to treat heart failure. The nurse should reinforce with the client that which of the following adverse effects is a possible indication of digoxin toxicity and should be reported to the provider?

The nurse is assisting in the care of the client who is at 30 weeks of gestation.

Nurses' Notes

1200:

Provided a quiet environment, dimmed the lights, and encouraged client to remain in bed in the side-lying position.

Encouraged client to cough and take deep breaths regularly.

Assisted with insertion of 18-gauge IV and initiation of IV fluid.

Assisted with insertion of indwelling urinary catheter per provider prescription. Maintained strict input/output monitoring; total intake 180 mL/hour.

FHR 136/min via external fetal monitor. Minimal variability noted, no contractions present.

1400:

Magnesium sulfate infusion ongoing.

Client is lethargic. Heart rate regular 58bpm, blood pressure 148/99 mmHg, respirations shallow DTR 1+ bilaterally.

Urine output 20 mL in the last hour

1405:

Assists with discontinuation of magnesium sulfate infusion Notifies provider of client status.

1800:

Client is alert and responsive. Heart rate regular 78bpm, respirations even and unlabored. DTR 2+ bilaterally

Oxygen saturation (SaO) 95% on 2 L nasal cannula. Respiratory rate 18/min. Blood pressure 146/96 mm Hg.

Select the findings that indicate the client's condition has improved.

A nurse on a medical-surgical unit is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?

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 supervising an assistive personnel (AP) who is applying antiembolic stockings for a client. Which of the following actions by the AP requires intervention by the nurse?