The nurse provides care for a client who is severely malnourished. A central venous access device (CVAD) is placed to administer total parenteral nutrition (TPN). Which laboratory result does the nurse closely monitor?

The nurse provides care to a toddler-age client and prescribed catheterization to obtain a urine specimen. Which procedure does the nurse implement? (Select all that apply)

An infant client has a tracheostomy. The nurse prepares to suction the tracheostomy. Which most important principle does the nurse use to plan care?

In which situation is the nurse determined to be negligent?

While the nurse prepares an injection for a client, the needle cap falls on the floor. Which action indicates that the injection will be sterile?

A young adult client has a partner and no children. The client has a hysterectomy because of endometrial cancer. The client has an IV and an indwelling urinary catheter. The client is crying asking for their partner. Which action does the nurse take first?

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.)

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 nurse provides care for a client who is severely malnourished. A central venous access device (CVAD) is placed to administer total parenteral nutrition (TPN). Which laboratory result does the nurse closely monitor?

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 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?