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 evaluating the laboratory values of a client who is receiving epoetin alfa. Which of the following findings indicates a therapeutic response to the medication?

A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider?

A nurse is providing client teaching about the basal body temperature method of birth control. Which of the following information should the nurse include in the teaching?

A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan?

A charge nurse notices that one of the nurses on the shift frequently violates unit policies by taking an extended amount of time for break. Which of the following statements should the charge nurse make to address this conflict?

A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?

A nurse is caring for an adolescent.
Admission Assessment
1400:

• Adolescent brought to emergency department by parents following a fall while skateboarding.
• Adolescent reports pain in . their right leg as 10 on a scale of 0 to 10 and is unable to bear weight.
• Adolescent is awake, alert, and oriented x 3.
• Lungs clear, respirations even and regular.
• S1 and S2 with regular rate and rhythm.
• Abdomen soft and nontender with active bowel sounds in all four quadrants.
• Right lower extremity with open wound and displaced bone.
• Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds.

Which of the following actions should the nurse take after the adolescent returns from surgery?

Select all that apply.

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 caring for a client who has a prescription for a continuous passive motion (CPM) machine following a total knee arthroplasty. Which of the following actions should the nurse take?

A client who had a knee replacement surgery and received a prescription for enoxaparin 30 mg subcutaneously every 12 hours for 10 days. The medication is available in 30 mg per 0.3 mL pre-filled syringes. How many mL should the practical nurse (PN) administer each day? (Enter numerical value only.)