A nurse is reviewing the medical history of a client who asks about the use of warfarin.
The nurse should identify which of the following findings as a contraindication for the administration of this medication?

A nurse is reinforcing teaching with a client who has an electrolyte imbalance. Which of the following foods should the nurse include as the highest in potassium?

A nurse is caring for an adolescent client who has cystic fibrosis.
Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage?

A nurse is caring for a client in active labor.

Admission Assessment.

0200:. Gravida 1, Para 0 at 39 weeks gestation.

Presents with.

contractions occurring every 5 to 6 min, 45 to 60 seconds.

duration.

Cervical examination 4 cm dilated, 50% effaced.

Admit.

to the labor and delivery unit.

Nurses' Notes.

0200:. Admitted to the labor and delivery unit, and reports pain as 7 on a scale.

of O to 10 with contractions.

Cervix 4 cm dilated, 50% effaced,with membranes intact.

0230:. The client reports increasing discomfort with contractions.

Cervix 5. cm dilated, 60% effaced, with membranes intact.

Contractions.

occurring every 5 min, 45 to 60 seconds duration.

0300:. Epidural anesthesia was initiated.

Cervix 7 cm dilated, 70% effaced,. with membranes intact.

Contractions occur every 4 to 5 min,60 seconds duration.

Vital Signs.

0200:. Temperature 36.9° C (98.4° F). Heart rate 86/min.

Respiratory rate 18/min.

BP 118/78 mm Hg. 0230:. Temperature 37° C (98.6° F). Heart rate 88/min.

Respiratory rate 20/min.

BP 120/80 mm Hg. 0300:. Temperature 37.1° C (98.8° F). Heart rate 90/min.

Respiratory rate 18/min.

BP 122/76 mm Hg. The nurse is assuming care for the client at 0305.

For each nursing action, click to specify if the nursing action is essential. contraindicated for the client.

A nurse is caring for a client on a psychiatric unit.

For each potential action, click to specify if the action is indicated or. contraindicated for the client.

A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community.
In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?

A nurse is caring for a client who experienced a traumatic brain injury 72 hr ago.
Which of the following findings should the nurse identify as a potential indication of increased intracranial pressure?

A charge nurse is teaching a newly licensed nurse about medication administration.
Which of the following information should the charge nurse include?

A nurse is caring for a 9-year-old child at a clinic.

Vital Signs.

1000:. Temperature 36.8°C (98.2 °F). Heart rate 102/min.

Respiratory rate 22/min.

BP 100/60 mm Hg. Oxygen saturation is 98% on room air.

Nurses' Notes.

1000:.The child has been brought to the clinic by their parent due to a. report of right arm pain.

The parent states that several hours.

ago the child tripped and fell onto the sidewalk while playing.

outside.

The child states, "I was running when we were playing,and I tripped over a curb." The child is supporting their arm across.

their body.

Assessment.

1000:The child is alert and appears developmentally appropriate for their.

age and well nourished.

Respirations are easy and unlabored.

Abdomen nondistended.

The right forearm and fingers are edematous.

Ecchymotic area.

noted on the outer aspect of the forearm.

Radial pulse +2. Fingers.

slightly cool to the touch.

A child can move fingers and reports a mild.

"tingling" sensation.

The child verbalizes a pain level of 4 on a scale.

of 0 to 10. Abrasion noted on the right knee.

No active bleeding.

Multiple areas of bruising were noted on the lower extremities in various.

stages of healing.

The nurse should determine that the assessment findings are consistent with.

which of the following conditions? For each potential condition, click to specify if the assessment findings are.

consistent with a sprain, a fracture, or dislocation.

Each finding may support this.

more than 1 condition.

A nurse is planning care for a group of clients and is working with one licensed practical nurse (LPN) and one assistive personnel (AP). Which of the following actions should the nurse take first to manage her time effectively?