A nurse is caring for a school-age child who is 2 hr postoperative following a cardiac catheterization.

The nurse observes blood on the child’s dressing.

A charge nurse is teaching new staff members about factors that increase a client’s risk to become violent.

Which of the following risk factors should the nurse include as the best predictor of future violence?

A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage?

A nurse is caring for a client who is receiving total parenteral nutrition (TPN).

The bag has 20 mL remaining to infuse, but a new bag is not readily available.

Which of the following actions should the nurse take?

A nurse is assisting with food selection for a client who follows kosher dietary traditions.

Which of the following food choices should the nurse include on the client’s food tray?

A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic.

Which of the following tasks should the nurse identify as tertiary prevention?

A staff nurse is observing a newly licensed nurse suction a client’s tracheostomy.

Which of the following actions by the newly licensed nurse requires intervention by the staff nurse?

A nurse in an emergency department is caring for a client. Nurses' Notes.

1200:.

Client is an 82-year-old male who presents with his adult child for evaluation of right arm pain after a fall. Client noted to have several superficial abrasions on right forearm and elbow. Also has numerous bruises in various stages of healing on arms and upper chest. Client rates pain in right lower forearm an 8 on a 0 to 10 pain scale and is not moving the arm.

1210:.

Client noted to keep head down and makes limited eye contact. Speaks very softly and looks at adult child before answering interview questions. Has strong body odor and clothes are unclean. Client's adult child answers most questions. Client grimacing and guarding right arm.

Client weighed, is 56.2 kg (124 lb) and 175 cm (69 in) tall. BMI 18.3.

1230:.

Client's adult child left facility to go home and get the client’s prescribed medications. Client visibly more relaxed and now speaking more openly to staff with improved eye contact. Client reports that he has lived with his adult child for the past several.

Vital Signs. 1200:.

Temperature 36.7° C (98° F). Heart rate 96/min.

Blood pressure 142/96 mm Hg. Respiratory rate 16/min.

SpO2 97% on room air.

The nurse is preparing to speak to the facility's Social Worker about the client's condition.

Select the 5 findings the nurse should plan to include in the report.

A nurse is providing discharge teaching about home care of a surgical incision to a client who speaks a different language from the nurse.

The nurse is communicating with the client using an interpreter.

Which of the following actions should the nurse take?

A nurse is caring for a client who requires seclusion to prevent harm to others on the unit.

Which of the following is an appropriate action for the nurse to take?

A nurse is teaching a client who has atrial fibrillation and is to start taking dabigatran.

Which of the following statements by the client indicates an understanding of the teaching?