A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse plan to take?

A nurse is assisting with feeding a client who has had a stroke. Which of the following findings should the nurse identify as a manifestation of dysphagia?

A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?

A nurse is reinforcing teaching with a client about advance directives. Which of the following client statements indicates an understanding of the teaching?

A nurse is preparing to set up a sterile field to change a sterile dressing on a client's
abdominal wound. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A nurse is collecting data from a client who has a BMI of 29. The nurse should document that the client is in which of the following weight categories?

A nurse is assisting in the care of a client.

Nurses' Notes

Day 1:

The client is receiving intermittent tube feedings via a nasogastric tube.

Abdomen is soft, nondistended.

Head of client's bed is positioned to 30° pH of gastric aspirate 4.0

Gastric residual volume is 50 mL Day 2:

Abdomen is distended. Client reports nausea and is coughing.

Gastric residual volume 550 mL pH of gastric aspirate 4.5

Nurses' Notes

Day 2:

Abdomen is distended. Client reports nausea and is coughing Gastric residual volume 550 mL

pH of gastric aspirate 4.5 Vital Signs

Day 2:

Temperature 37° C (98.6° F) Blood pressure 114/68 mm Hg Heart rate 110/min Respiratory rate 24/min

Pulse oximetry 90% on room air

Select the findings in the client's medical record that require further action by the nurse. To deselect a finding, click on the finding again.

Choices

Nurses' Notes Day 2:

Abdomen is distended. Client reports nausea and is coughing

Gastric residual volume 550 mL pH of gastric aspirate 4.5

Vital Signs

Day 2:

Temperature 37° C (98.6° F) Blood pressure 114/68 mm Hg Heart rate 110/min Respiratory rate 24/min

Pulse oximetry 90% on room air

A nurse is observing an assistive personnel (AP) provide postmortem care for a client prior to visitation by their loved ones. Which of the following actions by the AP requires intervention by the nurse?

A nurse is preparing to administer ampicillin to a school-age child who weighs 55 lb. The provider prescribes 50 mg/kg/day in 4 equal doses. Available is ampicillin oral suspension 125

mg/5 mL. How many mL should the nurse administer with each dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is caring for a client and observes a nurse from another unit reviewing the client's medical record. Which of the following actions should the nurse take?

A nurse is assisting with the care of a client who is experiencing dysphagia following a recent stroke. The nurse should initiate a referral to which of the following interprofessional team members?