A nurse is suctioning the airway of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following findings should the nurse identify as an indication that the suctioning has been effective?

A client is receiving IV fluids at 150 mL/hr. Which of the following findings indicates that the client is experiencing fluid overload?

A nurse is caring for a client who has signed an informed consent form to receive electroconvulsive therapy (ECT). The client states to the nurse, "I'm not sure about this now. I'm afraid it's too risky." Which of the following responses should the nurse make?

A nurse is caring for an adolescent.
Admission Assessment
1400:

• Adolescent brought to emergency department by parents following a fall while skateboarding.
• Adolescent reports pain in their right leg as 10 on a scale of 0 to 10 and is unable to bear weight.
• Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm.
• Abdomen soft and nontender with active bowel sounds in all four quadrants.
• Right lower extremity with open wound and displaced bone.
• Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds.

Select the 4 findings that require follow-up.

A nurse is caring for a client who is 1 hr postpartum.

Nurses' Notes

1200:

Large amount of lochia rubra noted on perineal pad. Fundus boggy at two fingerbreadths above the umbilicus. Oxytocin 20 units being administered via continuous JV infusion.

1215:

Large amount of lochia rubra with several large clots noted. Client reports feeling anxious. Skin cool and clammy. Provider notified.

Select the 6 actions the nurse should take.

A nurse in an outpatient mental health clinic is caring for a client.

Exhibit 1

Vital Signs

3 months ago:

Blood pressure 116/68 mm Hg

Heart rate 82/min

Respiratory rate 16/min

Temperature 36.7° C(98.1° F)

SaO2 97% on room air

Today:

Blood pressure 128/76 mm Hg

Heart rate 104/min

Respiratory rate 22/min

Temperature 37.4° C(99.4° F)

SaO2 97% on room air

Exhibit 2

Nurses' Notes

3 months ago:

Client recently admitted with new diagnosis of schizophrenia. Received inpatient treatment for 10 days and was discharged 1 week ago. Client is alert and oriented to person, place, time, and situation. Responds appropriately to questions. Client reports sleeping well and working at a local retail store.

Today:

Client presents for follow-up visit. Pressured speech noted.

Appears to be listening to unseen others. Client is restless.

Frequently getting out of chair. Appears tired and disheveled.

Exhibit 3

Graphic Record

3 months ago:

83.9 kg (185 lb)

Today:

83 kg(183 lb)

A nurse in an outpatient mental health clinic is caring for a client. Select the 3 findings that require immediate follow-up.

A nurse in a mental health clinic is assessing a client who has a history of seeking counseling for relationship problems. The client shows the nurse multiple superficial self-inflicted lacerations on their forearms. The nurse should identify these behaviors as characteristics of which of the following personality disorders?

A nurse is providing phone advice for a client who is pregnant.

Complete the following sentence by using the lists of options.

The client is at risk for experiencing

A nurse is assessing a client who has major depressive disorder and is taking amitriptyline. Which of the following findings should the nurse identify as an adverse effect of the medication?

A nurse is caring for a client during a follow up visit at a gastrointestinal clinic

Nurses' Notes

Client arrived today for follow up. Client reports worsening gastrointestinal symptoms. Client was last seen 2 months ago and reported abdominal pain and bloating. Today, the client reports worsening abdominal pain in the right lower. quadrant and abdominal bloating. Client reports frequent soft to loose stools today and denies tarry stools. Client also states that they have been experiencing a loss of appetite and some weight loss.

For each assessment finding, specify if the assessment findings are consistent with Crohn's disease, ulcerative colitis, or peritonitis. Each finding may support more than one disease process.

A nurse is providing teaching to the guardians of a newborn about measures to prevent sudden infant death syndrome (SIDS). Which of the following guardian statements indicates an understanding of the teaching?