The nurse reviews the entries in the medical record.

Admission Assessment 0900:
Client reports, "I'm bloated and my stomach hurts." History of prior illness: Client reports a 3-week history of gnawing abdominal pain. Client states, "It's a burning sensation that radiates to my back. I think I've lost a little weight too." Reports one episode of dark, tarry stool. No vomiting. Client reports pain is worse about 1 hr after eating a meal. Past medical history: Osteoarthritis
Social history: Recently divorced, drinks in moderation (3 to 4 drinks per week), smokes tobacco
Current medications:

Ibuprofen 800 mg three times daily PRN arthritis pain Physical Examination:

General: client appears uncomfortable, diaphoretic

Head, ears, eyes, nose, and throat (HEENT): oropharynx clear, mucous membranes moist and pale
Respiratory: bilateral breath sounds clear

Gastrointestinal: epigastric tenderness to palpation, no rebound tenderness or guarding Neurological: oriented x 3 (person, place, and time)

The nurse is ready to begin. For each potential nursing action, specify if the action is indicated or not indicated for the client.
Nursing Actions

A nurse is caring for a client who has a spinal cord injury.

Nurses' Notes 0600:

Adventitious lung sounds auscultated in lower lobes bilaterally. Spirometry encouraged. Cough productive for clear sputum.

1000:

Cough productive for clear sputum following incentive spirometry and coughing exercises. Face and neck flushed. Client reports headache.

Abdomen distended. Last bowel movement was 2 days ago with hard stool. Provider Prescriptions

Nifedipine 30 mg PO for blood pressure greater than 150/100 mm Hg and notify provider Acetaminophen 650 mg PO q4 hr PRN pain

For each potential nursing action, click to specify if the action is anticipated or contraindicated for the client.

A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse should recognize which of the following findings as an indication that the medication has been effective?

A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr. Which of the following interventions should the nurse anticipate?

A nurse is caring for a client who has been admitted to the antepartum unit.

Complete the following sentence by using the list of options.

The nurse should recognize the client is experiencing

A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?

A nurse is caring for a client in the medical-surgical unit.

Which of the following actions should the nurse take to decrease the risks for urinary tract infection for this client?
Select all that apply.

A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include?

A nurse is caring for a client who is in a coma and is scheduled for a surgical procedure.
Which of the following actions should the nurse take?

A nurse is preparing to administer levothyroxine 50 micrograms to a client. Available is levothyroxine 0.025 mg/tablet. How many tablets should the nurse administer per dose?
(Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is caring for a client who has a prescription for lactated Ringer's IV 4,080 mL/24 hr. The nurse should set the IV infusion pump to deliver how many mL/hr to administer half the total volume in the first 8 hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)