Which descriptions of stool warrant additional follow-up by the nurse? (Select all that apply.).

A client presents to the doctor's office with a report of fatigue and difficulty sleeping.
Which information should the nurse recognize as a potential contributing factor?

The nurse observes that a client is using accessory muscles. Which vital sign should the nurse obtain first?

A client is in contact isolation due to a stage IV coccyx wound infected with MRSA. The nurse plans interventions to prevent multiple infections.
Which intervention is most appropriate to prevent the spread of MRSA to others?

The nurse is preparing to administer Tylenol to a client admitted with urination issues who also has difficulty sleeping (OSA).
Which interaction is most important for the nurse to implement before leaving the client?

The nurse observes the skin over a client's greater trochanter, as seen in the picture with pressure sores.
What actions should the nurse implement?

What equipment should the nurse use to most accurately measure a 2ml dose of a viscous liquid solution to be given orally?

When using a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?

After a week of bed rest, a client is being assisted to a chair for the first time.
The nurse raises the head of the bed and moves the client to a sitting position. What should the nurse implement next?

After a long bed rest, a client with a Foley catheter and wrist restraints has repeatedly removed the antibiotic (G) tube and NG tube.
At checking the restraints, which action is most important for the nurse to take?

Two days after surgery, a male client experiences incisional pain while dangling his feet at the bedside and he refuses to ambulate as prescribed.
The nurse establishes a problem of 'Activity intolerance related to pain'. Based on this problem, which outcome statement is best for the nurse to include in his care plan?