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 in an emergency department is reviewing the medical record of a client who is having an acute myocardial infarction. Which of the following findings places the client at risk if he receives alteplase?

A nurse in a provider's office is caring for a client who asks about using acupuncture to manage his osteoarthritis pain. The nurse should identify which of the following conditions as a contraindication for receiving this treatment?

A client with Crohn's disease is preparing for discharge from the hospital following treatment for an exacerbation of diarrhea, abdominal pain, and rectal bleeding. Which dietary recommendation(s) should the nurse discuss with the client? (Select all that apply.)

A nurse is planning teaching for a client and their family about home oxygen therapy. Which of the following information should the nurse plan to include in the teaching?

A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following factors places the client at risk for aspiration?

A nurse is assessing a child who is postoperative following a tonsillectomy.
Which of the following findings should the nurse identify as the priority?

A nurse is creating a plan of care for a female client who has recurrent urinary tract infections. Which of the following interventions should the nurse include in the plan?

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

A nurse is planning care for a client who has a prescription for a bowel-training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care?