The nurse is assessing tube feeding residual amounts and finds 10ml of residual.

The client is receiving 60ml/hr of feeding.

What action should the nurse take?

A nurse is caring for a patient diagnosed with Hodgkin disease who has significant cervical lymph node enlargement.

Which symptom should the nurse address first?

A patient with a colostomy says, “My pouch blows up like a balloon when I pass gas.”. What is an appropriate response by the nurse?

A nurse is caring for a client who is to maintain a fluid restriction of 1,200 mL/24 hr. How many mL of fluids can the client have over the next 20 hr if the client had a total fluid intake of 300 mL during the first 4 hr of the shift?

A nurse is admitting a client. Review the exhibits to answer the question.

For each potential provider's prescription, click to specify if the prescription is anticipated or contraindicated.

A nurse is assisting a postoperative client.

The client is alert and oriented to person, place, and time, and reports incisional pain of 9 on a scale of 1 to 10. Morphine 8 mg was administered subcutaneously as prescribed at 0900.

The client is now sleeping and is difficult to arouse.

Pupils are 3 mm, equal and reactive to light.

Temperature is 37.5 C (99.5°), respirations are 10/min, and pulse oximetry is 87% on room air.

Which documentation in the client’s medical record requires further action by the nurse?

A nurse is contributing to the plan of care for a client who has urolithiasis.

Which of the following interventions should the nurse include in the plan?

A client has suffered a partial thickness second-degree burn injury of the chest, abdomen, and upper legs and is scheduled for hydrotherapy and debridement.

Which of these actions should the nurse take to effectively assist the patient?

The nurse is reviewing orders for a patient in anaphylactic shock.

Which medications should the nurse plan to administer first?

A nurse is assessing a client with a major burn injury.

Which of the following findings should the nurse prioritize?

A nurse is attending to a client who has suffered a basal skull fracture.

During the morning hygiene care, the nurse observes a thin clear drainage coming from the client’s right nostril.

What should be the nurse’s immediate action?