A nurse working in the emergency department (ED) is admitting a client.

Exhibits

The nurse is reviewing the client's medical record. Which of the following conditions should the nurse identify as a risk factor for pneumonia? Select all that apply.

A home health nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?

A nurse is caring for a client who is near the end of life and is on complete bed rest. The client states that he needs to have a bowel movement, and the nurse offers a bed pan. The client states, "I've always used the bathroom." Which of the following responses should the nurse make?

A nurse is conducting an initial assessment of a client and notices a discrepancy between the client's current IV infusion and the report received during the shift report. Which of the following actions should the nurse take?

A home care nurse is making a follow-up visit with a client who has COPD and is using a compressed oxygen system in his home. Which of the following actions should the nurse take?

A nurse is caring for a client in an acute care setting.

Complete the following sentence by using the list of options.

The client is at risk for

A nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis. Which of the following actions should the nurse include in the plan of care?

A nurse is providing care for a client who has esophageal cancer and has received radiation therapy. Which of the following findings should the nurse identify as the priority?

A nurse is caring for a client.

Select the 2 actions that the nurse should take.

A nurse is assessing the fontanels of an 8-month-old infant. Which of the following findings should the nurse recognize as an expected finding?

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

The nurse reviews the assessment findings.

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Assessment

Respirations easy and unlabored. Abdomen non-distended. Right forearm and fingers are edematous. Ecchymotic area noted on outer aspect of the forearm. Radial pulse +2. Fingers slightly cool to touch. Child can move fingers and reports a mild "tingling" sensation. Child verbalizes a pain level of 4 on a scale of 0 to 10. Multiple areas of bruising are noted on lower extremities in various stages of healing.

Vital Signs

Temperature 36.8° C (98.2° F)

Heart rate 102/min Respiratory rate 22/min

BP 100/60 mm Hg

Oxygen saturation 98% on room air