The nurse is continuing to care for the adolescent.

Admission Assessment

1400:

Adolescent brought to emergency department by parents following a fall while skateboarding. Adolescent reports pain in their right leg as 10 on a scale of 0 to 10 and is unable to bear weight.

Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with active bowel sounds in all four quadrants. Right lower extremity with open wound and displaced bone. Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds.

Which of the following prescriptions should the nurse anticipate from the provider?

A nurse is teaching a parent of a school-age child who is to begin a daily dose of methylphenidate. Which of the following should the nurse include in the teaching?

A nurse is reviewing the medical record of a client. These are the medical reports; Hypoactive bowel sounds upon auscultation, abdomen soft, not distended on palpation and urinary output of 130mL/4hr. Which of the following findings should the nurse report to the provider?

A nurse in an emergency department is assessing a school-age child who was brought in by their parents and has scald burns to both hands and wrists. The nurse suspects physical abuse. Which of the following actions should the nurse take?

A nurse is caring for a client during a follow up visit at a gastrointestinal clinic.

Nurses' Notes

0600:

Client admitted to the ED with fatigue, shortness of breath, and weakness for the last 2 days. Client states that they have a history of sickle cell disease (SCD). Client is alert and orientated to person, place, and time. Restless. Client rates generalized pain as a 9 on a scale of 0 to 10. Vital signs taken and blood drawn for laboratory tests. Oxygen 2 L via nasal cannula applied. Awaiting prescription for pain management.

0615:

Client still rates pain as a 9 on a scale of 0 to 10. Hydromorphone 4 mg IV administered.

Which of the following interventions should the nurse implement?

Select all that apply.

When performing a focused gastrointestinal system assessment, the practical nurse (PN) asks a male client when his last bowel movement occurred. The client answers, "Three days ago."

Which action should the PN implement first?

A nurse is caring for a client who is 1 hr postpartum.

Nurses' Notes

1200:

Large amount of lochia rubra noted on perineal pad. Fundus boggy at two fingerbreadths above the umbilicus. Oxytocin 20 units being administered via continuous JV infusion.

1215:

Large amount of lochia rubra with several large clots noted. Client reports feeling anxious. Skin cool and clammy. Provider notified.

Select the 6 actions the nurse should take.

A nurse is admitting a client to the psychiatric unit after attempting suicide. The client states, "My family does not care whether I live or die." Which of the following responses should the nurse make?

8-year-old male admitted with cystic fibrosis reports:

• Shortness of breath
• Wheezing throughout lung fields
• Productive cough with thick sputum

A nurse is creating a plan of care for a newly admitted child. Which of the following actions should the nurse include in the plan?

A nurse is caring for a client who has a prescription for 1 unit of packed RBCs. Five minutes after beginning the transfusion, the client becomes febrile with chills. After stopping the transfusion, which of the following actions should the nurse take?

A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?