A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

A nurse is caring for a client.

Nurses' Notes

Day 1:

1300:

Client has a 2.5 cm (1 in) x 2.5 cm (1 in) stage 2 pressure injury to dorsal lateral aspect of left heal; wound bed red, moist, approximated edges; surrounding skin inflamed, red,, non-tender to palpation. Client reports pain score of 0 on 0 to 10 pain scale. Pedal pulse left foot 1+, unable to assess capillary refill due to toe fungus bilaterally, Pedal pulse right foot 2+. Wound care as prescribed; heel floated on pillow.

Medical History

Day 1:

Diabetes mellitus Hyperlipidemia

Labs

Day 1

Hct 38% (37% to 47%)

Hgb 13 (12 g/dL to 16 g/dL)

WBC 11,500/mm3 (5000 to 10,000/mm3)

Potassium 3.6 mEq/L (3.5 mEq/L to 5 mEq/L)

Pre-albumin level 10 mg/dL (15 to 36 mg/dL)

Albumin: 3.0 g/dL (3.5 to 5 g/dL)

Fingerstick blood glucose, fasting 186 mg/dL (74 to 106 mg/dL)

Select the 5 findings that can cause delayed wound healing.

A nurse is caring for a client who is scheduled for an elective surgical procedure. Which of the following actions should the nurse take regarding informed consent?

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube.

Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

A nurse is caring for a client who is prescribed bedrest. The plan of care indicates that the client should perform isometric exercises every 2 hr. Which of the following actions should the nurse take as directed by the plan of care?

A nurse finds an open vial of morphine lying on top of the cabinet in a client's room. Which of the following actions should the nurse take?

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers.

Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

A nurse is performing a cardiac assessment. Identify where the nurse should place the stethoscope to auscultate the client's apical pulse. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

A nurse is providing hygiene care for a client who is immobile. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions?

A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?