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 caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first?

A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal?

A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?

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 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 in a clinic is interviewing a client who will undergo diagnostic testing The nurse should ask about a client's potential allerges during which phase of the nursing process?

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take?

A nurse is having difficulty caring for a client due to variables affecting the communication process. Which of the following should the nurse identify as an interpersonal variable? (Select all that apply.)

The family of an older adult client brings him to the emergency department after finding him wandering outside. During the initial assessment, the nurse notes that the client flinches when she palpates his abdomen yet responds to questions only by nodding and smiling.

Which of the following factors should the nurse identify as a likely explanation for the client's behavior?

A nurse is providing discharge teaching for a client who requires home oxygen therapy.

Which of the following statements should the nurse identify as an indication that the client needs further teaching?