A nurse is collecting data from a client who reports feeling stress. Which of the following should the nurse identify as an external stressor?

A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?

A nurse is caring for a client who is cyanotic and has a respiratory rate of 8/min with shallow respirations. Which of the following is the priority action by the nurse?

A nurse is reinforcing teaching for a client who has a new ascending colostomy. Which of the following comments by the client indicates an understanding of the teaching?

The nurse is reviewing the client's medical record.

Procedures

Planned endoscopy at 1300.

The nurse is assisting with the care of the client prior to a blood transfusion. Which of the following actions should the nurse take?

Select all that apply.

A nurse is monitoring a client who has received external radiation for throat cancer. Which of the following findings should the nurse expect?

A nurse is assisting with the care of a client who is receiving a spinal epidural to treat a herniated disc. Which of the following findings should the nurse identify as an indicator of unrelieved pain?

A home health nurse is conducting a home inspection for a client who is at risk for falls. Which of the following instructions should the nurse provide for the client?

A nurse working in a mental health facility is caring for a client who is pacing back and forth in the day room while wringing their hands. Which of the following actions should the nurse take?

A nurse is assisting in the care of an older adult client who was admitted from a long-term care facility.

Nurses' Notes 1500:

The client is restless and is not following commands. The client does not tolerate lying flat. Skin warm and dry. Regular heart sounds without murmur. Respirations labored. Breath sounds with the right-sidedcrackles and wheezes in the posterior lower lobe. Abdomen soft, nondistended with positive bowel sounds in all four quadrants. Tremors in hands.

Admission Assessment 1400:

The client's history includes cigarette smoking for 50 years but quit 3 years ago, Parkinson's disease, and anxiety. Yesterday, the client reported "feeling bad." The client is alert and oriented to self, reports upper chest discomfort, and is coughing up thick clear sputum.

Select the 3 findings that require immediate follow-up.

A nurse is collecting data from a client who has diabetic ketoacidosis. Which of the following findings should the nurse expect?