Exhibits

The nurse considers the brief interaction with the client and the triage report. What finding(s) should the nurse investigate further? Select all that apply.

Based on the assessment data, the nurse recognizes the need to intervene immediately. Select the 5 priority interventions that the nurse should initiate based on the most recent assessment.

The nurse is caring for a client who reports sudden right-sided numbness and weakness of the arm and leg. The nurse also observes a distinct right-sided facial droop. After reporting the findings to the healthcare provider, the nurse receives several prescriptions for the client, including a STAT computerized tomography scan of the head. Which intervention should the nurse should perform in the immediate management of the client?

Which breakfast selection should the nurse recommend for a 16-year-old with diarrhea?

The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection indicates to the nurse that the client understands the prescribed diet?

After years of struggling with weight management, a middle-aged adult client is evaluated for gastroplasty. The client has experienced difficulty with managing diabetes mellitus and hypertension, but is approved for surgery. Which intervention is most important for the nurse to include in this client's plan of care?

A client who received an open reduction and internal fixation (ORIF) of the right femur after experiencing a fall at home experiences a sudden onset of increasing confusion and agitation. When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?

The nurse discusses the need to balance energy intake and output to maintain weight.

Click to indicate whether the following actions would be effective or ineffective for this client to achieve energy balance. Each row must have one option selected.

A client is admitted to the intensive care until (ICU) with a spinal cord injury following a motor vehicle collision. Which nurse should be contacted to coordinate the progression of the client's care?

An older adult client with dementia who is refusing to allow an unlicensed assistive personnel (UAP) to assist in bathing, is becoming increasingly agitated and stating the UAP "wants to hurt me and fie me up." Which approach should the nurse use with the client?

A 4-month-old infant is brought to the clinic by a parent with symptoms of a runny nose, a slight fever and cough for the last two days. Which finding should alert the nurse that the child is in acute respiratory distress?