The emergency department (ED) triage nurse receives a report from emergency medical services (EMS) on an older adult client being brought to the ED via EMS. After receiving the report, the nurse reviews the client's electronic medical record (EMR) for history and the most recent medication list.

1635: Most recent entry from a visit to primary care provider 5 days ago. Vital signs were BP 164/90, HR 96, RR 20, T 96.7°F (35.9°C), and SpO2 96% on room air. Past Medical History (PMH) positive for osteoporosis, a history of ovarian cancer treated with a hysterectomy and chemotherapy 16 years ago, hypercholesterolemia, and hypertension being managed with diet and exercise. During this recent visit, the client was started on hydrochlorothiazide (HCTZ) 12.5 mg, 1 tablet PO every AM. No Known Drug Allergies (NKDA). Additional home medications include:

• Atorvastatin 20 mg PO, 1 tablet every PM
• Calcium 1000 mg, 1 tablet PO BID
• multi-vitamin, 1 capsule PO every AM

The nurse obtained the bloodwork, started the IV, and administered morphine IV push.

> Complete the following sentence:

The nurse's highest priority is planning care knowing that the client is at risk for seizures due to

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The nurse delegated vital signs for a group of patients to the unlicensed assistive personnel (UAP). Which client condition would prohibit having a rectal temperature taken by the UAP?

A young adult client has a partner and no children. The client has a hysterectomy because of endometrial cancer. The client has an IV and an indwelling urinary catheter. The client is crying asking for their partner. Which action does the nurse take first?

The nurse provides care for a child with an abdominal wound. The wound edges are approximated. Which does the nurse include when rendering the prescribed wound care to this child? (Select all that apply)

While the nurse prepares an injection for a client, the needle cap falls on the floor. Which action indicates that the injection will be sterile?

The nurse plans care for a client who reports avoiding people because of having scabies and difficulty walking. Which statement does the nurse document as the client's greatest concern?

The nurse provides care for a patient with an infected surgical wound. The nurse assesses the wound and changes the dressing. Which does the nurse include in the documentation? Select all that apply.

The nurse provides care for a client diagnosed with pneumonia. The client is unable to expectorate respiratory secretions. The nurse suctions the client's nasopharyngeal airway. When is suctioning technique correct?

The nurse provides care for a client recovering from a motor vehicle crash. For which sign of fluid volume overload does the nurse measure the client's intake and output? (Select all that apply)

The emergency department (ED) triage nurse receives a report from emergency medical services (EMS) on an older adult client being brought to the ED via EMS. After receiving the report, the nurse reviews the client’s electronic medical record (EMR) for history and the most recent medication list.

15:45: Client transferred to ED Bed 5 via stretcher by EMS. The client's spouse is at the bedside. Client states "I feel so much better now, except for my wrist is really hurting." Advised will assess then check with the ED physician about something for the pain. VS BP 112/68, HR 99, RR 20, T 98.4° F (36.9° C), SpO2 96% on room air. The client is alert and oriented (A&O) x 4, pleasant, and cooperative. PERRLA, skin intact with no bruising except for dorsal left forearm and wrist which is ecchymotic and edematous. Radial pulses strong and equal (+3), fingers warm with capillary refill < 3 sec. Lungs are clear, abdomen soft with bowel sounds x 4 quadrants, pedal pulses (+) x 4, and no pedal edema.

The nurse assesses the client and reviews the orders from the ED physician, gathers supplies to draw the lab work, starts the IV, and administers the morphine IVP.

Select the supplies the nurse gathers (Select all that apply.)

The nurse is caring for a client with a diagnosis of a ruptured appendix who underwent an emergency exploratory laparotomy with appendectomy 48 hours ago.

The 55-year-old client was admitted through the Emergency Department (ED) with fever, chills, nausea, and diffuse abdominal pain. Computed tomography (CT) of the abdomen confirmed a ruptured appendix with widespread inflammation. The client is 6'1" (193.04 cm) tall and weighs 260 lbs (117.93 kg). The client is obese with a BMI of 31.6 kg/m2. The client underwent an immediate exploratory laparotomy with appendectomy. The wound was not closed and was packed with sterile gauze.

The client's past medical history includes gastric reflux disease (GERD), hypertension, and type 2 diabetes mellitus. The client has no known drug allergies (NKDA). Home medications include lisinopril 20 mg 1 tablet PO every day, omeprazole 40 mg 1 capsule PO every day, metformin ER (extended-release) 750 mg 1 tablet PO every day, and acetaminophen 325 mg 2 tablets PO every 4 hours PRN for pain.

The physician is notified of the change in the client's wound. The nurse receives orders to obtain blood cultures x 2 and a culture of the wound now. The nurse prepares to change the client’s abdominal dressing and obtain a wound culture.

Which steps are appropriate for this procedure? (Select all that apply.)