A nurse is monitoring a client who is receiving a transfusion of packed RBCs.
The client reports chills, headache, low-back pain, and a feeling of "tightness" in his chest.
The nurse should identify that the client has developed which of the following types of transfusion reactions?

A nurse is caring for an adolescent who has hyperthermia. Which of the following actions should the nurse take?

The nurse reviews the entries in the medical record.

Admission Assessment 0900:
Client reports, "I'm bloated and my stomach hurts." History of prior illness: Client reports a 3-week history of gnawing abdominal pain. Client states, "It's a burning sensation that radiates to my back. I think I've lost a little weight too." Reports one episode of dark, tarry stool. No vomiting. Client reports pain is worse about 1 hr after eating a meal. Past medical history: Osteoarthritis
Social history: Recently divorced, drinks in moderation (3 to 4 drinks per week), smokes tobacco
Current medications:

Ibuprofen 800 mg three times daily PRN arthritis pain Physical Examination:

General: client appears uncomfortable, diaphoretic

Head, ears, eyes, nose, and throat (HEENT): oropharynx clear, mucous membranes moist and pale
Respiratory: bilateral breath sounds clear

Gastrointestinal: epigastric tenderness to palpation, no rebound tenderness or guarding Neurological: oriented x 3 (person, place, and time)

The nurse is ready to begin. For each potential nursing action, specify if the action is indicated or not indicated for the client.
Nursing Actions

174. A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider?

A nurse is caring for a client.

Nurses' Notes 0900:

Client reports a 3-month history of intermittent diarrhea and abdominal pain. Reports unintentional weight loss of 5.5 kg (12 lb) in 3 months.

0930:

Stool sample obtained for fecal occult blood test. Fatty appearance and foul odor noted.

For each assessment finding, click to specify if the finding is consistent with ulcerative colitis, diverticulitis, or Crohn's disease. Each finding may support more than 1 disease process.

A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take?

A nurse is caring for a female client who requests a contraceptive diaphragm. Which of the following actions should the nurse take first?

A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?

A nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis. Which of the following actions should the nurse include in the plan of care?

A nurse is caring for a client who has been admitted to the antepartum unit.

History and Physical Day 1,0900:

30-year-old client at 33 weeks gestation, Gravida 4 Para 3 Maternal blood type: Rh+

Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks gestation. Nurses' Notes

Day 1, 0900:

Client reports lower back pain and pinkish vaginal discharge.

Uterine contractions every 8 minutes, palpate strong, duration 30 seconds. FHR baseline 145, minimal variability.

Cervical exam indicates 2 cm, 50% effaced, 0 station. Membranes intact.

CBC and urinalysis collected and sent to lab.

Highlight the findings that require follow-up.