A nurse is caring for a client who is postoperative following an appendectomy.

Vital Signs

1800:

Temperature 98.4° F (36.8° C) Heart rate 104/min

Respiratory rate 22/min

Blood pressure 142/80 mm Hg

O2 saturation 97% on room air

1800:

Client alert and oriented x 4

Skin warm and dry

Lungs clear on auscultation

Bowel sounds hypoactive in all four quadrants Urine clear yellow

Incisional dressing clean and dry

Client reports pain as 6 on a scale of 0 to 10

1815:

Morphine administered as prescribed

2000:

Temperature 98.4° F (36.8° C) Heart rate 110/min Respiratory rate 24/min

Blood pressure 158/88 mm Hg O2 saturation 93% on room air

Which of the following 4 client findings should the nurse report to the provider?

A nurse is assigning task roles for a group of clients in a community mental health clinic. Which of the following tasks should the nurse assign to the member of the group functioning as the orienteer?

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 on a pediatric unit has received change-of-shift report for four children. Which of the following children should the nurse assess first?

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 in an emergency department is caring for a child who has a fever and fluid-filled vesicles on the trunk and extremities. Which of the following interventions should the nurse identify as the priority?

A nurse is providing teaching about advance directives to a middle adult client. Which of the following client responses indicates an understanding of the teaching?

A nurse is caring for a client who is immediately postoperative following a subtotal thyroidectomy.

Vital Signs

1100:

Temperature 37.4° C (99.4° F) Heart rate 98/min Respiratory rate 18/min

Blood pressure 128/68 mm Hg

Pulse oximetry 97% on room air

1115:

Temperature 37.8° C (100.1° F) Heart rate 110/min Respiratory rate 16/min

Blood pressure 138/74 mm Hg

Pulse oximetry 95% on room air

1130:

Temperature 38.6° C (101.5° F). Heart rate 136/min

Respiratory rate 16/min

Blood pressure 154/86 mm Hg

Pulse oximetry 95% on 2 L/min via nasal cannula

Select the 4 client findings that lead the nurse to suspect that the client is experiencing thyroid storm.

A nurse is developing a client education program about osteoporosis for older adult clients. The nurse should include which of the following variables as a risk factor for osteoporosis?

A nurse is assessing for correct placement of a client's NG feeding tube prior to administering a bolus feeding. Which of the following actions should the nurse take?

A nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following interventions should the nurse include in the plan?