Review H and P and nurses’ notes.

Exhibits

Click to highlight which assessment findings should the nurse attend to right away?

Admitted client. Vital signs: heart rate 128 beats/minute, rhythm sinus tachycardia, respiratory rate 14 breaths/minute, oxygen saturation 100% on 40% fraction of inspired oxygen, temperature 96.9° F (36.1° C), blood pressure 90/79 mm Hg. Pulse pressure calculated to be less than 40 mm Hg. The client's surgical dressing is clean and dry. Ecchymosis noted on the abdomen around the dressing. The client has a peripheral intravenous line in the right forearm and one in the left hand. The client also has a right subclavian central venous catheter that is infusing propofol and intravenous fluids.

An adult is admitted with acute flank pain, a 102° F (38.9° C) oral temperature, hematuria, dysuria, urgency, and fishy-smelling urine. Which admitting prescription(s) are most important for the nurse to implement? Select all that apply.

The nurse is caring for a client who reports running out of aspirin 1 week ago and taking ibuprofen as a replacement. Which information should the nurse obtain from the client first?

The nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

The client has recovered from surgery and is ready to be discharged.

Highlight findings that indicate the client is stable and ready to be discharged.

The client returned from appendectomy surgery last night at approximately 2100. The client was admitted for observation due to a delay in waking from anesthesia. The client is currently resting in bed. The incision dressing is dry and intact, and no bleeding is noted. The client tolerated clear liquids post recovery and has advanced to a soft diet. The client ambulated around the unit this morning and tolerated activity well. Bowel sounds are present in all 4 quadrants, and per client report, she has passed flatus. Pain is tolerated with analgesia PO.

The home health nurse makes a home visit to a client with amyotrophic lateral sclerosis (ALS). The client is sitting upright while feeding themself and coughs frequently during the meal.

Which action should the nurse implement?

A client presents to the clinic with fatigue, poor appetite, general malaise, and vague joint pain that improves mid-morning. The client has been taking over-the-counter Ibuprofen for several months. The healthcare provider makes an initial diagnosis of rheumatoid arthritis (RA). Which laboratory test(s) should the nurse report to the healthcare provider? Select all that apply.

The nurse is concerned about the client's temperature. Which interventions can the nurse use to address the client's temperature? Select all that apply.

The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?

After removing a client's dressing that is saturated with sanguineous drainage, where should the nurse place the dressing?

The healthcare provider places orders to determine the cause of client symptoms.

Use the chart to indicate if the listed symptom or finding is consistent with gastroenteritis, appendicitis, or ectopic pregnancy.

Each row must have at least one, but may have more than one, response option selected.