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 2-month-old infant who has heart failure. Which of the following actions should the nurse take?

A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching as an example of malpractice?

A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan?

A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse?

A nurse is assessing a client who is taking haloperidol and is experiencing pseudoparkinsonism. Which of the following findings should the nurse document as a manifestation of pseudoparkinsonism?

A charge nurse is observing a conflict between two nurses who both insist that the charge nurse favors the other when making assignments. Which of the following conflict-resolution strategies should the charge nurse use?

A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?

Urine dipstick:
pH 6.0 mg/dl. (4.6 to 8 mg/dL)

Specific Gravity 1.022 (1.010 to 1.025)

Leukocyte esterase negative (Negative)

Nitrite negative (Negative)

Protein trace negative (Negative)

Glucose negative (Negative)

Ketones none (None)

Bilirubin none (None)

Blood none (None)

Which of the following statements should the nurse include in the client's teaching?

Select all that apply.

A nurse is caring for a client who has been admitted to the antepartum unit.
Nurses' Notes Day 1,0900:
Client reports lower back pain and pinkish vaginal discharge. Uterine contractions every 8 minutes, palpate strong, duration 30 seconds.
FHR baseline 145, minimal variability.

Cervical exam indicates 2 cm, 50% effaced, 0 station. Membranes intact.
CBC and urinalysis collected and sent to lab.

Vital Signs Day 1,

0900:

Admission:

Temperature 38.4° C (101.1° F) Heart rate 92/min Respiratory rate 18/min Blood pressure 130/78 mm Hg
Pre-pregnancy BMI 27.6 Current BMI 29.9

The client is at risk for developing which of the following 2 complications? Select 2 complications the client is at risk of developing.