A nurse is collecting data from a client who has left sided heart failure. For which of the following findings should the nurse notify the provider?

A nurse is reinforcing teaching about advance directives with a client who has end-stage heart failure.

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

A nurse is administering pancrelipase to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment?

A nurse is assisting with the care of a client in a medical-surgical unit.

Vital Signs

05:00

Temperature 36.6 C (97.9 F) Heart rate 100/min Respiratory rate 22/min

Blood pressure 160/98 mm Hg

Oxygen saturation 96% on oxygen 2 L/min via nasal cannula 14:00

Temperature 36.8 C (98.3 F) Heart rate 90/min Respiratory rate 18/min

Blood pressure 138/88 mm Hg

Oxygen saturation 97% on oxygen 2 L/min via nasal cannula

Which of the following actions should the nurse take to decrease the risks of a urinary tract infection for this client?

Select all that apply.

A nurse is caring for an older adult client who reports dry, itchy skin. Which of the following actions should the nurse take?

A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hr PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this client care incident?

A nurse is participating in a performance improvement program. Which of the following actions should the nurse take to evaluate the effectiveness of the program?

A nurse is caring for a client who has paranoid schizophrenia and believes that they are being followed by FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make?

A nurse in a mental health facility is caring for a client who reports palpitations and a sense of impending doom. Which of the following actions should the nurse take first?

A nurse is assisting with the care of a client.

Laboratory Results

Abdominal ultrasound: mass present in small intestine proximal to the ileocecal valve. The size of mass is 6 cm x 7

cm (2.4 in x 2.8 in).

Select the 4 responsibilities the nurse has in relation to the client's advance directives.

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.