A nurse is caring for a client who is postoperative following the administration of general anesthesia.

Exhibits

Select from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

The nurse is continuing to care for the adolescent.

Admission Assessment

1400:

Adolescent brought to emergency department by parents following a fall while skateboarding. Adolescent reports pain in their right leg as 10 on a scale of 0 to 10 and is unable to bear weight.

Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with active bowel sounds in all four quadrants. Right lower extremity with open wound and displaced bone. Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds.

Which of the following prescriptions should the nurse anticipate from the provider?

A nurse is caring for a client who is pregnant.

Exhibit 1

Nurses' Notes

1000:

The client reports repeated episodes of vomiting and two episodes of diarrhea in past 24 hr. Client is at 18 weeks of gestation and reports a history of nausea and vomiting for the past 12 weeks.

1015:

IV fluids initiated. Prochlorperazine administered via intermittent IV bolus.

1100:

Client reports improvement in nausea. Ice chips provided. Client voided 50 mL of dark yellow urine.

1500:

Client tolerating fluids well. Ate four graham crackers without emesis. Has voided 300 mL of amber-colored urine.

Exhibit 2

Vital Signs

1000:

Temperature 36.8° C(98.2° F)

Heart rate 112/min

Respiratory rate 20/min

Blood pressure 100/65 mm Hg

SaO 97% on room air

1200:

Temperature 37° C(98.6° F)

Heart rate 102/min

Respiratory rate 20/min

Blood pressure 104/70 mm Hg

SaO2 98% on room air

1500:

Temperature 36.8° C(98.2° F)

Heart rate 90/min

Respiratory rate 18/min

Blood pressure 110/72 mm Hg

SaO2 97% on room air

For each discharge instruction, specify if each action is recommended or contraindicated for the client.

A school nurse is performing scoliosis screenings. The nurse should recognize which of the following clinical manifestations as an indication of scoliosis?

A nurse is caring for a 2-month-old infant who has Hirschsprung disease (HD). Which of the following areas should the nurse assess for manifestations of HD?

(You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

An antepartum nurse is caring for four clients. For which of the following clients should the nurse initiate seizure precautions?

A charge nurse notices that one of the nurses on the shift frequently violates unit policies by taking an extended amount of time for break. Which of the following statements should the charge nurse make to address this conflict?

A nurse is suctioning the airway of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following findings should the nurse identify as an indication that the suctioning has been effective?

A nurse is providing teaching to a school-age child who has asthma about using an albuterol metered-dose inhaler. Which of the following instructions should the nurse include?

A nurse is teaching a client who has a new prescription for an MAOI. Which of the following foods is contraindicated with this medication?

A nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following activities is the nurse's priority?