A nurse is performing a fall risk assessment on a client. Which of the following findings indicates the client has an increased fall risk?

A nurse in the emergency department is managing the care of a client who has an electrical shock injury. Which of the following actions should the nurse take first?

A nurse is caring for a client in the emergency department.

1400:

Client admitted to the medical-surgical unit at 1200 today. Alert and orientated x4, heart and lung sounds clear. Client urinating 100 mL/hour. Client is tolerating soft diet and oral fluids. Bowel sounds are hyperactive in all 4 quadrants. Bilateral pedal pulses 2+. Blood glucose 310 mg/dL (74 to 106 mg/dL)

Click to highlight the findings that indicate that the client's condition is improving. To deselect a finding, click on the finding again.

1400:

Temperature 36.8° C (98.2° F)

Pulse rate 84/min

Respiratory rate 16/min

Blood pressure 106/76 mm Hg

Oxygen saturation 96% on room air

A nurse is caring for a client in the emergency department.

A nurse is admitting a client who reports tightness in their chest that radiates to left arm.

Click to highlight the findings below that would indicate that the client has a potential problem. To deselect a finding, click on the finding again.

Client reports tightness in chest that radiates to left arm. States pain as 7 on a scale of 0 to 10. Started to feel nauseous after breakfast. Client states, i had scrambled eggs and bacon like I do every morning." Client is diaphoretic and short of breath. Heart rate is irregular and tachycardic. Alert and oriented to person, place, and time. Lungs clear to auscultation in all lobes. Bowel sounds are present in all 4 quadrants. +1 pedal pulses. Skin is cool to touch. Capillary refill less than 2 seconds.

A nurse is caring for a client who has a herniated disc and is scheduled for a peripheral nerve block. The client tells the nurse, "I am afraid to have this procedure." Which of the following responses should the nurse make?

A nurse is caring for a client who has left-sided heart failure. Which of the following manifestations should the nurse expect?

A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first?

A nurse is planning care for a client who has a new diagnosis of acute pancreatitis. Which of the following interventions should the nurse include in the plan of care?

A home health nurse is assessing a client who has pernicious anemia. Which of the following is an expected manifestation that poses a risk to the client's safety?

A nurse is assessing a female client who has pneumonia. The nurse should identify which of the following findings increases the client's risk of skin breakdown?