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

Client reports to clinic for monthly prenatal visit. Client is at 20 weeks of gestation. Since last visit, client reports concern about the occurrence of intermittent mild backaches, increased heartburn, generalized itching, and vaginal discharge. Which one of the following statements should the nurse include in the clients teaching? Select all that apply

A nurse is teaching a client who has chronic pain about avoiding constipation from opioid medications. Which of the following information should the nurse include in the teaching?

A nurse is caring for a client in the outpatient mental health clinic

Click to highlight the findings that indicate the client is experiencing adverse effects of the medication. To deselect a finding, click on the finding again
Nurses' Notes
Today

Client states "I’m feeling much better." They report less fatigue even though they have difficulty sleeping. Client reports they are not sad anymore but are experiencing more frequent headaches. Client continues to deny any suicidal ideation

Vital Signs
Today
BP 149/91 mm Hg

Heart rate 75min

Respiratory rate 18/min

A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?

A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices." Which of the following responses is the priority for the nurse to state?

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.)

A nurse is teaching a client who has rheumatoid arthritis about illness management. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client.

Nurses' Notes 0900:

Client reports a 3-month history of intermittent diarrhea and abdominal pain. Reports unintentional weight loss of 5.5 kg (12 lb) in 3 months.

0930:

Stool sample obtained for fecal occult blood test. Fatty appearance and foul odor noted.

For each assessment finding, click to specify if the finding is consistent with ulcerative colitis, diverticulitis, or Crohn's disease. Each finding may support more than 1 disease process.

A nurse is caring for a client who presents to the emergency department.