The nurse is reviewing the medical records of the client who is exhibiting mania. Which of the following actions should the nurse take? Select all that apply.

Vital Signs 0800:

Heart rate 110/min Respiratory rate 20/min

Blood pressure 132/80 mm Hg Temperature 37.2° C (99° F)

1100:

Heart rate 120/min

Respiratory rate 24/min

Blood pressure 149/90 mm Hg Temperature 37.2° C (98.9° F)

A nurse is reinforcing teaching with a client who has a new prescription for enoxaparin. The nurse should identify which of the following over-the-counter products as unsafe for use with enoxaparin.

A nurse is assisting with a community health presentation about home safety precautions when there is an outdoor chemical disaster nearby. Which of the following instructions should the nurse include?

A nurse is reinforcing teaching with another nurse about how to change an ostomy appliance for a client who has a sigmoid colostomy. Which of the following instructions should the nurse include in the teaching?

A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder. Which of the following findings should the nurse expect 15 minutes following the procedure?

Nurses' Notes Postoperative Day 3 0900:

The client reports pain at the surgical incision site as 5 on a scale of 0 to 10. The client reports bladder fullness. Perineal dressing intact with minimal serosanguinous drainage. The client transferred out of bed to a chair independently. Extremities cool and dry with 2+ peripheral pulses.

1300:

The client reports abdominal cramping and small, hard, painful bowel movements after lunch. Ambulating independently in the hallway. Reports pain as 8 on a scale of 0 to 10. Urinary catheter intact with 100 mL/hr. of pink urine.

Select the 2 actions the nurse should prepare to take for the client.

A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. The nurse should place the client in which of the following positions?

A nurse is reinforcing teaching with a client who is taking allopurinol about the risk for developing Stevens-Johnson syndrome. For which of the following manifestations should the nurse instruct the client to monitor and report?

Nurses' Notes Preoperative 0730:

The client is scheduled for a left stapedectomy.

Pupils 3.5 mm, equal, round, and reactive to light. Smile symmetrical.

Mucous membranes show color expected for the client's skin tone and moisture.

Speech clear.

Skin warm and dry. Lungs clear bilaterally.

Apical heart rate regular at 78/min. Postoperative

1230:

Pupils were 3 mm, equal, and reactive to light.

Smile asymmetrical. Mucous membranes pink. Speech hoarse.

Client with left facial droop Skin warm and dry.

The client reports vertigo and nausea.

Bilateral breath sounds clear and present throughout. Apical heart rate regular at 92/min.

The client reports left ear discomfort and rates the pain as 5 on a scale of 0 to 10. The client states that her hearing has diminished following surgery.

Which of the following findings requires further action by the nurse? Select all that apply.

A nurse in a provider's office is caring for a group of clients who have communicable diseases. Which of the following infections should the nurse report to the state health department?

A nurse is assisting with postmortem care for a client who was a devout follower of Islam. Which of the following actions should the nurse take?