A staff nurse is observing a newly licensed nurse suction a client's tracheostomy. Which of the following actions by the newly licensed nurse requires intervention by the staff nurse?

A nurse is preparing to obtain a health history from a client who is on bedrest. Which of the following positions should the nurse take to place the client at ease?

The nurse reviews the entries in the medical record.

Admission Assessment 0900:
Client reports, "I'm bloated and my stomach hurts." History of prior illness: Client reports a 3-week history of gnawing abdominal pain. Client states, "It's a burning sensation that radiates to my back. I think I've lost a little weight too." Reports one episode of dark, tarry stool. No vomiting. Client reports pain is worse about 1 hr after eating a meal. Past medical history: Osteoarthritis
Social history: Recently divorced, drinks in moderation (3 to 4 drinks per week), smokes tobacco
Current medications:

Ibuprofen 800 mg three times daily PRN arthritis pain Physical Examination:

General: client appears uncomfortable, diaphoretic

Head, ears, eyes, nose, and throat (HEENT): oropharynx clear, mucous membranes moist and pale
Respiratory: bilateral breath sounds clear

Gastrointestinal: epigastric tenderness to palpation, no rebound tenderness or guarding Neurological: oriented x 3 (person, place, and time)

The nurse is ready to begin. For each potential nursing action, specify if the action is indicated or not indicated for the client.
Nursing Actions

A charge nurse is delegating care for a group of clients. Which of the following tasks should the charge nurse assign to a licensed practical nurse?

A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following factors places the client at risk for aspiration?

A nurse is caring for a school-age child who is postoperative and received morphine via IV bolus for pain 10 min ago. Which of the following findings is the nurse's priority?

A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take?

A nurse is teaching a prenatal class about infection prevention at a community center.
Which of the following statements by a client indicates an understanding of the teaching?

A nurse is caring for a client in a clinic.

Vital Signs 0915:

Temperature 36.7° C (98° F)

BP 122/80 mm Hg Respiratory rate 20/min Heart rate 99/min

Nurses' Notes 0900:

A 16-year-old client reports to the clinic with their caregiver. The client's caregiver informs the nurse that the client has "not been themselves lately." The client's parents and a sibling passed away from injuries sustained when a tornado moved through their town 1 month ago. They were the only survivors and witnessed their family's deaths.

0910:

The client appears anxious but answers appropriately for age. They report experiencing nightmares that awaken them at night and startle easily during thunderstorms, but the client admits that they have always been afraid of thunderstorms. The client admits to smoking marijuana for about 1 month because it helps clear their mind. They also admit that they have no desire to leave the house. They attend school regularly and are on the honor roll.

Based on the information in the client's medical record, which of the following findings requires immediate follow-up?

Select the 4 findings that require follow-up.