When caring for a patient with burns, which assessment data will alert the nurse to the possibility of a local infection of the burned area?

A nurse is assisting a postoperative client.

The client is alert and oriented to person, place, and time, and reports incisional pain of 9 on a scale of 1 to 10. Morphine 8 mg was administered subcutaneously as prescribed at 0900.

The client is now sleeping and is difficult to arouse.

Pupils are 3 mm, equal and reactive to light.

Temperature is 37.5 C (99.5°), respirations are 10/min, and pulse oximetry is 87% on room air.

Which documentation in the client’s medical record requires further action by the nurse?

A nurse is caring for a patient diagnosed with Hodgkin disease who has significant cervical lymph node enlargement.

Which symptom should the nurse address first?

A nurse is caring for a client who is to maintain a fluid restriction of 1,200 mL/24 hr. How many mL of fluids can the client have over the next 20 hr if the client had a total fluid intake of 300 mL during the first 4 hr of the shift?

A nurse is explaining to a client who is preparing for emergency surgery due to a small bowel obstruction.

The client is anxious and doesn’t understand what the surgeon means by “adhesions” causing the blockage.

Which of the following statements is the best response from the nurse?

A nurse is assisting with the care of a client in the emergency department. Review the exhibits to answer the question.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

The nurse is performing pin care for a patient with an external fixation device for a fractured tibia.

Which assessment finding by the nurse should be reported to the unit care coordinator?

A nurse is admitting a client. Review the exhibits to answer the question.

For each potential provider's prescription, click to specify if the prescription is anticipated or contraindicated.

A nurse is attending to a client who has suffered a basal skull fracture.

During the morning hygiene care, the nurse observes a thin clear drainage coming from the client’s right nostril.

What should be the nurse’s immediate action?

Following an explosion at a local chemical lab, several people have sustained burns and are now in the triage area.

Which patient should be attended to first?

A client with a terminal illness asks the nurse, “If I have a DNR prescription, does that mean I will no longer receive any treatment for my condition?” Which of the following statements should the nurse provide to explain a DNR prescription?