While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA), which is the most important action for the nurse to take?

Patient Data

Which are the nurse's best responses? Select all that apply.

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 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 mg/dL (9.3 mmol/L) and a two-hour postprandial of 220 mg/dL (12.2 mmol/L).

The nurse reviews nurses' notes to determine what the client's obstetric history reveals in the form of GTPAL.

Choose the most likely option for the information missing from the statement by selecting from the list of options provided.

Based on the client's obstetrical history, the client's G-T-P-A-L designation is

When conducting diet teaching for a client who is on a postoperative full-liquid diet, which food(s) should the nurse encourage the client to eat? (Select all that apply.)

The practical nurse (PN) and unlicensed assistive personnel (UAP) enter a client's room and find the client lying on the bed. The PN determines that the client is unresponsive. Which instruction should the PN give the UAP first?

Immediately after log-rolling a client to a lateral position, which intervention should the practical nurse (PN) implement?

The practical nurse (PN) is caring for an older client who is receiving chemotherapy for lung cancer. Which finding is the highest priority for the PN to report to the charge nurse?

Reference ranges:

• Blood urea nitrogen (BUN): [Adult: 10 to 20 mg/dL or 3.6 to 7.1 mmol/L]
• Platelets: [150,000 to 400,000/mm3 or 150 to 400 x 10^9/L]

The practical nurse (PN) observes an unlicensed assistive personnel (UAP) performing oral hygiene on an unconscious client who is lying in a flat side-lying position with an emesis basin on the bedside table near the chin. Which action should the PN take?

The healthcare provider prescribed octreotide 150 mcg/day subcutaneously for a client with dumping syndrome. The medication is available in 0.2 mg/mL vials. How many mL should the practical nurse (PN) administer? (Enter numerical value only. If rounding is required, round to the nearest hundredth).

A client is receiving IV heparin and oral warfarin after a pulmonary embolism (PE). The nurse determines the client's activated partial prothromboplastin time (APTT) value is two times the control value; the prothrombin time (PT) level is the same as the control, and the international normalized ratio (INR) is 1. Which protocol prescription should the nurse implement?

Reference Range:

Activated Partial Prothromboplastin Time (APTT) [Anticoagulant therapy: 1.5 to 2 times the control value in seconds.] Prothromboplastin Time (PT) [Anticoagulant therapy: greater than 1.5 to 2 times the control value.] International Normalized Ratio (INR) [0.8 to 1.1]

The client is a 32-year-old multigravida at 28 weeks' gestation, who presents to the obstetrician's office for a routine has given burn 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 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 mg/dL (9.3 mmol and a two-hour postprandial of 220 mg/dL (12...mol/L).

Scheduled the client to meet with the obstetrician, Diabetic Nurse Educator, and a Registered Dietician for the next day. After a discussion about gestational diabetes and seeking the client's input, a suggested plan of care is outlined, which includes dietary control and glucose self-monitoring.

The registered dietician (RD) discusses the need to

Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided.

The diabetic nurse educator instructs the client to perform fingerstick blood glucose (FSBG) monitoring Select Response