Exhibits

Which of the following actions should the nurse assist with? (Click on the exhibit tabs for additional information about the client.)

A nurse is assisting in the care of a client who is in the emergency department (ED) following a ski accident.

The nurse is collecting data on the client. Which of the following findings require follow up?

Select all that apply.

Which of the following actions should the nurse assist with? (Click on the exhibit tabs for additional information about the client.)

A nurse is reinforcing teaching with a client who has herpes simplex virus type 2. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is assisting in the care of the client who is postoperative following a fasciotomy.

Which of the following actions should the nurse take? Select all that apply.

A nurse is assisting in the care of the client who is postoperative following a fasciotomy.

The nurse is reviewing the client's electronic medical record (EMR). Click to highlight the statements in the EMR that indicate the client's condition is improving since implementing interventions. To deselect a finding, click on the finding again

Nurses' Notes

Day 3, 2300:

Client is alert and oriented to person, place, and time. Bilateral breath sounds clear and present throughout. Right leg with splint in place. Incisional dressing dry and intact. Wound drain to negative-pressure vacuum, draining small amounts of serosanguinous fluid. Bilateral pedal pulses 3+. Feet warm with intact movement and sensation. Client reports pain as a 4 on a scale of 0 to 10.

Vital Signs

Day 3, 2300:

Temperature 37.8° C (100° F)

Blood pressure 120/58 mm Hg

Heart rate 98/min

Respiratory rate 20/min

Oxygen saturation 95% on room air

A nurse is contributing to the plan of care for a client who has AIDS and has malnutrition. Which of the following actions should the nurse include in the plan of care?

A nurse is admitting a client who reports excessive thirst, fever, and periods of confusion. The nurse suspects the client is experiencing heat exhaustion. Which of the following electrolyte imbalances should the nurse expect?

A nurse is transporting a client who has pneumonia and is on droplet precautions to radiology. Which of the following safety measures should the nurse take while transporting the client?

A nurse in an assisted living facility is collecting data from an older adult client who fell in their room and hit their head on the dresser. Which of the following findings is the nurse's priority?

A nurse is reinforcing teaching with a client who is premenopausal. Which of the following statements by the nurse is appropriate regarding breast self-examinations?