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 nurse is teaching a parent of a school-age child who is to begin a daily dose of methylphenidate. Which of the following should the nurse include in the teaching?

A nurse is assessing a client after administering epinephrine for an anaphylactic reaction. Which of the following findings should the nurse identify as an adverse effect of this medication?

A nurse is caring for a client who had a stroke 6 hr ago. Which of the following interventions should the nurse implement to reduce the risk of increased intracranial pressure (ICP)?

The nurse is assessing the adolescent 4 hr following fasciotomy. Highlight the findings below that indicate the adolescent's condition is improving.

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.

Nurses' Notes 2300:

Adolescent is drowsy and reports nausea. Respirations shallow. Lungs clear. Unproductive cough present. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with hypoactive bowel sounds in all four quadrants. Right lower extremity fasciotomy, dressing clean, dry, and intact. Extremity pulse +3. Capillary refill 2 seconds. Right extremity is warm to the touch. Adolescent reports no numbness or tingling. Adolescent reports pain as 2 on a scale of 0 to 10.

A nurse is caring for a client whose partner died in a fire that destroyed their home. Which of the following actions should the nurse take first?

A nurse is developing a client education program about osteoporosis for older adult clients. The nurse should include which of the following variables as a risk factor for osteoporosis?

A nurse is caring for a client who has a prescription for a continuous passive motion (CPM) machine following a total knee arthroplasty. Which of the following actions should the nurse take?

A nurse is admitting a client who has pneumonia. The nurse should initiate which of the following isolation precautions for the client?

A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider?

A nurse is preparing to administer PRN pain medication to a client who has cholelithiasis and is experiencing moderate abdominal pain. Which of the following medications should the nurse plan to administer?