The nurse provides care for a patient with an infected surgical wound. The nurse assesses the wound and changes the dressing. Which does the nurse include in the documentation? Select all that apply.

The nurse omits to document an assessment finding that resulted in a significant client injury. For which legal issue does the nurse need to prepare?

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?

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 6'1" (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.

The client's past medical history includes gastric reflux disease (GERD), hypertension, and type 2 diabetes mellitus. The client has no known drug allergies (NKDA). Home medications include lisinopril 20 mg 1 tablet PO every day, omeprazole 40 mg 1 capsule PO every day, metformin ER (extended-release) 750 mg 1 tablet PO every day, and acetaminophen 325 mg 2 tablets PO every 4 hours PRN for pain.

The physician is notified of the change in the client's wound. The nurse receives orders to obtain blood cultures x 2 and a culture of the wound now. The nurse prepares to change the client’s abdominal dressing and obtain a wound culture.

Which steps are appropriate for this procedure? (Select all that apply.)

The nurse provides care for a client diagnosed with pneumonia. The client is unable to expectorate respiratory secretions. The nurse suctions the client's nasopharyngeal airway. When is suctioning technique correct?

The nurse provides care for a child with an abdominal wound. The wound edges are approximated. Which does the nurse include when rendering the prescribed wound care to this child? (Select all that apply)

In which situation is the nurse determined to be negligent?

The nurse plans care for a client who reports avoiding people because of having scabies and difficulty walking. Which statement does the nurse document as the client's greatest concern?

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)

A client recovering from surgery sits in a chair for breakfast. Which action does the nurse take before applying newly prescribed anti-embolism stockings to the client's lower extremities?