A nurse is performing a dressing change on a client and observes granulation tissue. Which of the following findings should the nurse document?

A nurse is reviewing a client's intake and output and notes the following: 0.9% sodium chloride 600 mL IV infusion, cefazolin 250 mg in dextrose 5% in water 100 mL intermittent IV bolus, 200 mL emesis, 40 mL voided urine, and 20 mL urine from straight catheterization. The nurse should record the difference between the intake and output as how many mL? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is caring for a group of clients. Which of the following actions by the nurse demonstrates client advocacy?

A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who are confused. Which of the following instructions should the staff nurse include?

A nurse has initiated an incident report for a missed dose of medication on a client that caused no harm to the client. Which of the following responses by the nurse manager indicates the use of just culture?

A nurse is caring for a client who is postoperative.

Click to highlight the documentation in the client's medical record that requires further action by the nurse. To deselect documentation, click on the documentation again.

Temperature 37.5° C (99.5° F)

Client is difficult to arouse.

Respiratory rate 10/min

Pulse oximetry 88% on room air (95% to 100%)

Pupils are 3 mm, equal, and reactive to light.

Blood pressure 99/46 mm Hg

Heart rate 61/min

A nurse is admitting a client who has been diagnosed with stage 4 cancer and is scheduled for surgery. Which of the following actions should the nurse take?

A nurse is assessing a client who has posttraumatic stress disorder following the occurrence of a natural disaster. Which of the following questions should the nurse ask to identify the client's support systems?

A nurse is caring for an older adult client newly admitted to the medical unit.

Click to highlight the pieces of information that indicate the client is at risk for falls. To deselect a piece of information, click on that piece of information again.

Nurses' Notes

1000:

An older adult client admitted following a fall down approximately five steps. Client's partner reports client possibly hit their head and was a little disoriented for a minute or two. Client states, "I feel fine. I just slipped." Client has a history of falls and orthostatic hypotension per client's partner. Client uses a walker and wears rubber-soled slippers at home. Client ordered new glasses following an eye exam last week but has not received them yet. Partner states they both do exercises that focus on coordination, three times per week.

Vital Signs

1000:

Temperature 37° C (98.6° F)

Heart rate 72/min Respiratory rate 20/min

Blood pressure

Lying: 130/90 mm Hg

Sitting: 128/88 mm Hg

Standing: 98/60 mm Hg

Oxygen saturation 97% on room air

A nurse is assessing an older adult client who reports pain. Which of the following should the nurse recognize about the client's perception of pain?

A nurse is creating a plan of care for a client who has left-sided hemiplegia. Which of the following interventions should the nurse include?