A nurse is caring for a client who was admitted for observation following a head injury. Which of the following findings by the nurse indicates the client is experiencing increased intracranial pressure?

A nurse on a medical-surgical unit is preparing to assist with the admission of clients who were injured in a tornado. Which of the following clients should the nurse recommend for discharge to make room for the new admissions?

A nurse is using a glucometer to measure a client's capillary blood glucose level. Which of the following actions should the nurse take?

A nurse is caring for a client who follows a kosher diet. Which of the following menu items should the nurse include on the tray?

A nurse is collecting data from a client who is taking tranylcypromine and reports ingestion of tyramine-rich foods. The nurse should monitor the client for which of the following findings as an adverse effect of this medication?

A nurse is about to administer an intermittent enteral feeding to a client who has an NG tube in place. Besides obtaining an x-ray, which of the following methods should the nurse use to verify the placement?

A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take?

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 reinforcing teaching with a client who is at 16 weeks of gestation and has a prescription for ferrous sulfate to treat iron-deficiency anemia. Which of the following recommendations should the nurse make to improve the absorption of the medication?

A nurse in an adult day care facility is contributing to the plan of care for a client whose family reports recent confusion and memory loss.

Which of the following strategies should the nurse include in the plan?

A nurse is caring for a newly admited older adult client.

Nurses' Notes

Day 1, 12:00:

Transferred to medical-surgical unit from emergency department (ED) for continued care following a closed reduction and immobilization of a fracture of the right arm. Accompanied by adult child.

Client in visibly soiled night clothes with multiple stains, including what appears to be dried blood. Hair, teeth, and fingernails unclean. Strong body odor noted. Bruising of various stages noted around upper arms, back, shoulders, and neck area.

Client is soft-spoken, speaks almost in a whisper, does not make eye contact with nurse.

Client looks at their child before answering the nurse's questions and, when asked how the injury occurred, mumbles "I don't know. Ask them." Client's child states, "He gets confused sometimes. I can answer your questions."

Which of the following interventions should the nurse recommend to include in the client's plan of care?

Select all that apply.