The nurse is obtaining morning vital signs and assessing a 64 year old female client who was admitted with community acquired pneumonia over night. The client is sleeping in supine position, however, she is easily arousable, alert and oriented, and reports no complaints at this time. The client's vital signs are: blood pressure 132/68, heart rate 88 beats per minute, respiratory rate 24 breaths per minute. O2 saturation 87% on 2L nasal cannula oxygen. What is the nurse's first priority action?

While reading a physician's progress notes a student notes that an assigned client is having hypoxia. What abnormal assessments would the student expect to find?

A student nurse is collecting a sterile urine specimen from an indwelling catheter. How will the student nurse correctly obtain the specimen?

A nurse caring for a patient who is hospitalized following a right knee replacement is preparing a discharge plan for the patient. Which action should be the focus of this termination phase of the helping relationship?

When caring for your patient, she states, "If I wait too long and let my bladder get too full, I can not hold in my urine. I have to wear a pad so I don't wet my pants." What is this type of incontinence called?

A patient tells their nurse "I am scared about my surgery tomorrow". The nurse's response to the patient is "everything will be fine, you have nothing to worry about". This comment by the nurse would be considered which type of communication block?

A 65 year old client is being seen at the outpatient clinic for a routine physical exam. The abdominal assessment shows distention, firmness, and the client states tenderness throughout the 4 quadrants. Upon further questioning of the client the following is determined; a slight decrease in appetite. consumes 320 mL of water per day along with 320 mL of other fluids such as coffee and soda, snacks frequently on cheese and crackers rather than full meals, and does not get much activity. Client states they have one to two bowel movements per week of hard formed stool. Based on the physical assessment and the answered questions what would be the recommended interventions for this client?

SELECT ALL THAT APPLY.

A 73 year old client has been admitted to the hospital for their respiratory disease of COPD. The client states that they have no appetite and eat very little throughout the day due to shortness of breath. The client also states that they have lost significant amounts of weight over the past several months. The nurse caring for the client is concerned that the client may be suffering from malnutrition. Which lab value would the nurse want to check to determine if the client is malnourished?

A client has been prescribed a clear liquid diet. What food or fluid will not be served?

The client is complaining of soreness around the stoma site. The nurse notes proper drainage in the bag, however, the surrounding skin is red, irritated, and moist. How will the nurse interpret this assessment?

A nurse is caring for a client who is being treated for a bladder infection. The client complains to the nurse that he has been having difficulty and it feels uncomfortable when he voids. How should the nurse document this client's condition?