Patient Data

Exhibits

Based on the trending heart rate and pain score, what should the nurse do? Select all that apply.

A client with end-stage lung disease is dependent on a mechanical ventilator to sustain life. While the client's spouse is at the bedside, the client pleads in handwritten notes to have the endotracheal tube removed. The spouse tearfully agrees with the request. Which is the priority nursing intervention?

After obtaining an oxygen saturation level of 94% for a client with pneumonia who is receiving oxygen via nasal cannula at 3 L/minute, the nurse observes a red mark on the client's right cheek. Which intervention should the nurse implement?

The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

A client, who speaks very little English, is being seen in the emergency department following an automobile accident. The client's sibling offers to act as an interpreter and asks about the laboratory results. Which response is best for the nurse to provide?

The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style of shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?

The nurse is caring for a client with obstructive sleep apnea. The nurse should recognize that the client is at greater risk for the development of which complication?

The nurse is explaining perineal care to the caregiver of a male client. Which information should the nurse include?

During the admission assessment to the hospital, an adult client reports being allergic to latex, penicillin, and bananas. Which intervention should the nurse implement first?

An unlicensed assistive personnel (UAP) assigned to feed a client with meningococcal infection, for whom droplet precautions have been implemented, requests a change in assignment, reporting they have not yet been fitted for an N95 respirator mask. Which action should the nurse take?

While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, formed, and light brown. Which action should the nurse implement?