When caring for a client with full-thickness burns to both lower extremities, which assessment finding(s) warrant immediate intervention by the nurse? (Select all that apply.)

An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction and lens implantation. Which intervention is most important for the nurse to implement to help ensure the client's compliance with self-care?

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

One hour after arriving on the postoperative unit, a woman who received spinal anesthesia 5 hours ago is complaining of severe abdominal incisional pain. Her vital signs are: temperature 99° F (37.2° C), heart rate 110 beats/minute, respiratory rate 30 breaths/minute and blood pressure 160/90 mmHg. The client's skin is pale, and the surgical dressing is dry and Intact. Which intervention is most important for the nurse to Implement?

The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement?

What should the nurse include in pre-discharge education for this child's parents? Select all that apply.

When the nurse enters the room of a male client who was admitted for a fractured femur, his cardiac monitor displays a normal sinus rhythm (NSR), but he has no spontaneous respirations and his carotid pulse is not palpable. Which intervention should the nurse implement?

Which instruction should the nurse delegate to an unlicensed assistive personnel (UAP)?

The client is a 32-year-old multigravida at 28 weeks' gestation, who presents to the obstetrician's office for a routine prenatal visit. Obstetrical history reveals she has given birth three times; once at 35 weeks (twins), once at 38 weeks (singleton) and once at 41 weeks (singleton). All of these children are alive and well. She had one spontaneous abortion at 10 weeks' gestation. Her fourth child weighed 9 pounds (4.08 kg) at 41 weeks gestation.

The nurse is reviewing nurses' notes to determine if there are any variations.

Click to highlight the findings that would indicate the client has developed a complication related to pregnancy.

Client is at 28 weeks. She has been receiving prenatal care since 8 weeks' gestation. Her fasting 1-hour glucose screening level, which was done 1 week prior, is 164 mg/dl. (9.1 mmol/L) Her 3-hour oral glucose tolerance test results reveal a fasting blood sugar of 168 (9.3 mmol/L) and a two-hour postprandial of 220 mg/dL (12.2 mmol/L).

Click to mark whether the following are signs and symptoms of cerebral edema, respiratory distress, or both.

The healthcare provider prescribes 5% Dextrose Injection, USP with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care?

Reference Range

• Potassium [Reference Range: 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]
• Glucose [Reference Range: 0 to 50 years: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)]