While performing a routine assessment, a nurse notices fraying on the electrical cord of a client’s continuous passive motion (CPM) device.

Which of the following actions should the nurse take first?

A nurse is assisting with food selection for a client who follows kosher dietary traditions.

Which of the following food choices should the nurse include on the client’s food tray?

A nurse is providing discharge teaching to the partner of a client who has a tracheostomy.

Which of the following information should the nurse include in the teaching

A nurse is reviewing the laboratory data of a client who received 2 units of packed RBCs.

Which of the following laboratory findings should the nurse expect following the transfusion?

A nurse is providing discharge teaching about home care of a surgical incision to a client who speaks a different language from the nurse.

The nurse is communicating with the client using an interpreter.

Which of the following actions should the nurse take?

A nurse is providing information for a client who has a new prescription for simvastatin. For which of the following should the nurse instruct the client to monitor and report to the provider?

A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr.

Which of the following interventions should the nurse anticipate?

A nurse is caring for a client in a clinic.

Exhibit 1 Exhibit 2.

Nurses' Notes.

0900:

A16-year-old client reports to the clinic with their caregiver. The client's caregiver informs the nurse that the client has "not been themselves lately." The client's parents and a sibling passed away from injuries sustained when a tornado moved through their town 1 month ago. They were the only survivor and witnessed their family's deaths.

0910:.

Client appears anxious but answers questions appropriately for age. They report experiencing nightmares that awaken them at night and startle easily during thunderstorm, but the client admits that they have always been afraid of thunderstorms. Client admits smoking marijuana for about 1 month because it helps clear their mind. They also admit that they have no desire to leave the house. They do attend school regularly and are on the honor roll.

Vital Signs.

0915:

Temperature 36.7° C (98° F).

BP 122/80 mm Hg Respiratory rate 20/min Heart rate 99/min.

Based on the information in the client's medical record, which of the following findings require immediate follow-up?

Select the 4 findings that require follow-up.

A nurse is caring for a client who has an implanted venous access port.

Which of the following should the nurse use to access the port?

A charge nurse is observing a conflict between two nurses who both insist that the charge nurse favors the other when making assignments.

Which of the following conflict-resolution strategies should the charge nurse use?

A staff nurse is observing a newly licensed nurse suction a client’s tracheostomy.

Which of the following actions by the newly licensed nurse requires intervention by the staff nurse?