Nurses' Notes Postoperative Day 3 0900:

The client reports pain at the surgical incision site as 5 on a scale of 0 to 10. The client reports bladder fullness. Perineal dressing intact with minimal serosanguinous drainage. The client transferred out of bed to a chair independently. Extremities cool and dry with 2+ peripheral pulses.

1300:

The client reports abdominal cramping and small, hard, painful bowel movements after lunch. Ambulating independently in the hallway. Reports pain as 8 on a scale of 0 to 10. Urinary catheter intact with 100 mL/hr. of pink urine.

Select the 2 actions the nurse should prepare to take for the client.

A nurse is collecting data from a client who has thrombocytopenia. The nurse should identify which of the following findings increases the client's risk for injury.

A nurse is preparing to administer haloperidol 0.5 mg by mouth to an older adult client. The amount available is haloperidol oral concentrate 2 mg/mL. How many mL should the nurse administer?

A nurse is reinforcing discharge teaching with a client who has stable angina pectoris. Which of the following statements by the client indicates an understanding of what to do when chest pain occurs?

A nurse is assisting with the care of a client.

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Nurses' Notes 1000:

The client states, "I am tired of undergoing treatment because it doesn't seem to be working." The client states, "I hope I am just constipated." Appendectomy scar on the right lower quadrant. The abdomen is soft, and tender in the right lower quadrant, bowel sounds present in all four quadrants.

1200:

The surgeon has notified the client that surgical removal of the mass is advisable due to the client's history of metastasis and ongoing treatment failure. The client and their partner want to discuss end-of-life care. The client states, "I am unsure what it means to have a living will or a do not resuscitate order." The client's partner states, "I don't understand what power of attorney means." Both client and partner indicate that they might wish to decline further treatment as well as further lifesaving measures should they become necessary. The partner states, "How can we be sure that our decision about care will be honored?"

Select the responsibilities the nurse has in relation to the client's advance directives.

A nurse is providing change of shift report for a client. Which of the following information should the nurse include in the report?

A nurse is assisting with postmortem care for a client who was a devout follower of Islam. Which of the following actions should the nurse take?

A nurse in a mental health facility is caring for a client who expresses anxiety about exercising in the outdoor courtyard. The nurse promises to walk with the client in the courtyard each day. Which of the following ethical principles is the nurse demonstrating?

A nurse is reviewing the medical records of five clients. For which of the following events should the nurse write an incident report? (Select all that apply.)

A nurse is reinforcing teaching with a client who has a new prescription for enoxaparin. The nurse should identify which of the following over-the-counter products as unsafe for use with enoxaparin.

A nurse is assisting with the care of a preschooler who has manifestations of respiratory syncytial virus. Which of the following actions should the nurse take?