A nurse is providing change-of-shift report about a client to an oncoming nurse. Which of the following information should the nurse include?

A nurse in an antepartum unit is caring for a client.
 

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Nurses' Notes

2230:

Contractions occurring every 2.5 to 3 minutes, lasting 60 to 70 seconds. Epidural placed by anesthesiologist. Client rates pain with contractions as a 3 on a scale of 0 to 10. FHR 150/min with moderate variability. Accelerations present, no decelerations noted.

Vital Signs

2230:

Temperature 38° C (100.4° F)

Heart rate 88/min

Respiratory rate 16/min

Blood pressure 122/80 mm Hg

Oxygen saturation 98% on room air

A nurse at a health department is providing anticipatory guidance to the parent of a 1-month-old infant. The nurse should inform the parent that the infant should receive which of the following immunizations at the age of 2 months?

A nurse is assessing a client who has dehydration due to prolonged diarrhea. Which of the following findings should the nurse expect?

A nurse is teaching a client who has GERD about appropriate dietary choices. Which of the following food choices by the client indicates an understanding of the teaching?

A nurse is assessing a client who is 2 days postoperative following a transurethral resection of the prostate and has an indwelling urinary catheter in place. Which of the following findings should the nurse expect?

A nurse is admitting a client to the medical-surgical unit. The Patient Self-Determination Act requires the nurse to perform which of the following actions during the admission process?

A nurse is preparing to administer medication to a client and discovers that a nurse on the previous shift gave the client an incorrect dose of the medication. Which of the following actions should the nurse take?

A nurse is preparing to administer timolol eye drops to a client who has glaucoma. In which order should the nurse perform the following steps? (place the steps , placing them in the order of performance.)

Verify the clarity and color of the eye drops.

Tilt the client's head backward toward the ceiling.

Pull the client's lower lid down with the nondominant hand.

Administer the prescribed number of drops.

Apply gentle pressure to the client's punctum.

A nurse is assessing a client who is in mechanical restraints after hitting a staff member. Which of the following findings indicates that the nurse should discontinue the restraints?

A nurse is assessing a client who has schizophrenia and is taking risperidone. Which of the following adverse effects of the medication is the priority finding for the nurse to report to the provider?