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?

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.)

A family member tells the nurse, "I overheard a caregiver threaten my uncle." The family member said the caregiver remarked, "If you don't learn to calm down, I will have to restrain you." Based on this information, which criminal offense does the nurse communicate to the nurse manager?

The nurse omits to document an assessment finding that resulted in a significant client injury. For which legal issue does the nurse need to prepare?

The nurse is caring for a senior adult client with three diagnoses of Parkinson's disease and an exacerbation of COPD. The nurse observes the unlicensed assistant personnel (UAP) providing morning care and obtaining vital signs by using a portable electronic blood pressure cuff and clip-on pulse oximetry sensor.

Nurse's Notes: Vital Sign # 0715: Client sitting up in bed with oxygen 2.1 per nasal cannula (NC) on. Clear pink skin and warm and dry lungs with scattered wheezes throughout. The client complains of shortness of breath and states, "I feel so much better than I did a couple of days ago." Mild tremors were noted. The client states, "My hands shake all the time."

1140: Client is still in bed with oxygen 2.1 per NC on, scattered wheezes throughout, and coarse rhonchi, which are clear with coughing. Cough is productive of yellow phlegm. Skin cool and dry. The client complains of shortness of breath or discomfort and states, "I like to keep it chilly in my room to help me breathe."

1140: The UAP reports to the nurse that the client's SpO2 is decreased.

Q1. After assessing the patient and reviewing the vital signs, which nursing action is appropriate to address the decreased SpO2?

(Select all that apply.)

A client receives a diagnosis of right-sided paralysis. Which action does the nurse take when assisting the client in transferring from the bed to the wheelchair?

In which situation is the nurse determined to be negligent?

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)

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 nurse evaluates a client's plan of care. The client has an outcome of 'Client will learn self-glucose testing before discharge'. When evidence best allows the nurse to meet the outcome of the plan?

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 6'4" (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.

Past Medical History (PMH) includes gastric reflux disease (GERD), hypertension, and type 2 diabetes mellitus. The client has no known drug allergies (NKDA). Home medications include:

1. Lisinopril 20 mg, 1 tablet PO every day
2. Omeprazole 40 mg, 1 capsule PO every day
3. Metformin ER (extended-release) 750 mg, 1 tablet PO every day
4. Acetaminophen 325 mg, 2 tablets PO every 4 hours PRN

The nurse medicates the client for pain prepares to irrigate the wound and completes the dressing change. The nurse observes a gush of fluid and sees a small portion of the client's intestine protrude from the wound bed. What actions does the nurse take immediately?