A nurse is considering placing wrist restraints on a client who has cognitive deficits and has pulled out their IV catheter. Before using wrist restraints, which of the following actions must the nurse take first?

A nurse is planning to use nonpharmacological pain relief methods for a client who reports continued mild back pain after receiving analgesia 1 hr ago. Which of the following actions should the nurse include in the plan?

A nurse is preparing to document in the client's medical record. The nurse should identify that which of the following abbreviations are specified by The Joint Commission for placement on a facility's Do Not Use list? (Select all that apply.)

A nurse is providing information to a client about durable power of attorney. The nurse should include that durable power of attorney is enforceable under which of the following conditions?

A home health nurse is performing a fall risk assessment for an older adult client. Which of the following findings should the nurse identify as a potential fall risk in the home?

A nurse is assessing a client who has hypocalcemia. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is ambulating a client who is unsteady. The client begins to fall. Which of the following actions should the nurse take?

A nurse is caring for a client who is scheduled for an appendectomy.

Exhibit 1 Exhibit 2 Exhibit 3

Nurses' Notes

1050:

Received handoff report from the ED nurse for a client who has acute appendicitis and is scheduled for an appendectomy. Client reports that pain began in the midabdominal region during the night. This morning the pain intensified and localized to the right lower quadrant region. Pain continues to intensify. rebound tenderness noted. Reports vomiting one time after eating a piece of toast at 0600 with continued feelings of nausea.

Peripheral IV to the left forearm with IV fluids infusing.

1200:

Informed consent obtained by the surgeon performing the procedure. Placed in the client's medical record. Client expressing concern about potential complications that could result from the surgery.

Medical History

1050:

Received influenza vaccine 1 month ago.

Thyroid disease, taking levothyroxine for 14 years. History of cholecystectomy 3 years ago.

Denies alcohol or illegal drug use. Reports smoking approximately 6 cigarettes per day for the past 10 years. Allergic to shellfish, latex, and penicillin.

Vital Signs

0945, Upon admission to emergency department (ED): Temperature 38.3°C(100.9° F)

Pulse rate 102/min Respiratory rate 22/min

Blood pressure 122/80 mm Hg Oxygen saturation 96% on room air Pain reported as 6 on a scale of 0 to 10.

1050, Upon admission to medical-surgical department Temperature 38,4° C (101.2° F)

Pulse rate 104/min Respiratory rate 22/min

Blood pressure 124/80 mm Hg Oxygen saturation 96% on room air Pain reported as 8 on a scale of 0 to 10

The nurse is preparing the client for surgery. Select the 4 findings that require follow-up prior to surgery.

A nurse enters a client's room to perform a focused assessment. Which of the following client information should the nurse use to properly identify the client?

A nurse is caring for a client who has recently retired from their job. The client states they feel like they no longer have a purpose. Which of the following responses should the nurse make?

A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?