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A nurse in an emergency department is caring for a client.
Physical Exam 1200: Influenza with nausea, vomiting, and diarrhea for 3 days. Client is tachycardic, hypotensive, and tachypneic, with weak pulses, dry mucous membranes, poor turgor, and oliguria. Plan: Admit for IV fluids
Vital signs 1200: Temp 38.4 C (101.1 F), HR 126/min, RR 28/min, BP 92/54 mm Hg, O2 Sat 93%
Nurses notes 1900: Client is disoriented, confused. Client attempting to get out of bed without assistance and states, "Im going home." Returned to bed, attempted to reorient to time, place, and circumstances. Call placed to clients family, no answer, message left. 1915: Client remains disoriented. Attempting to pull out IV line. Call was returned by clients family. Updated them on situation.
Complete the following sentence by using the options list. The nurse should first ______ followed by _____.
A nurse in an emergency department is caring for a client. Physical Exam 1200: Influenza with nausea, vomiting, and diarrhea for 3 days. Client is tachycardic, hypotensive, and tachypneic, with weak pulses, dry mucous membranes, poor turgor, and oliguria. Plan: Admit for IV fluids Vital signs 1200: Temp 38.4 C (101.1 F), HR 126/min, RR 28/min, BP 92/54 mm Hg, O2 Sat 93% Nurses notes 1900: Client is disoriented, confused. Client attempting to get out of bed without assistance and states, "Im going home." Returned to bed, attempted to reorient to time, place, and circumstances. Call placed to clients family, no answer, message left. 1915: Client remains disoriented. Attempting to pull out IV line. Call was returned by clients family. Updated them on situation. Complete the following sentence by using the options list. The nurse should first ______ followed by _____.
The nurse should first review medications that might cause confusion followed by using other methods to keep the client safe.
The nurse is evaluating teaching for a client who has heart failure. Which of the following 3 statements by the client indicates an understanding of the teaching?
The nurse is evaluating teaching for a client who has heart failure. Which of the following 3 statements by the client indicates an understanding of the teaching?
A nurse is caring for a client who is postoperative following abdominal surgery. Click to highlight the assessment findings below that the nurse should report to the provider. To deselect a finding click on the finding again.
A nurse is caring for a client who is postoperative following abdominal surgery. Click to highlight the assessment findings below that the nurse should report to the provider. To deselect a finding click on the finding again.
A nurse is caring for a client in a medical-surgical unit. After reviewing the assessment findings. Which of the following actions should the nurse plan to take? Select the 3 actions that the nurse should plan to take.
A nurse is caring for a client in a medical-surgical unit. After reviewing the assessment findings. Which of the following actions should the nurse plan to take? Select the 3 actions that the nurse should plan to take.
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A nurse is providing teaching for a client who has diarrhea. Select the 4 instructions that the nurse should include in the teaching?
A nurse is providing teaching for a client who has diarrhea. Select the 4 instructions that the nurse should include in the teaching?
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A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The clients partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?
A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The clients partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?
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A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?
A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?
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A nurse is planning care of an adolescent who is postoperative following a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care?
A nurse is planning care of an adolescent who is postoperative following a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care?
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A nurse in a surgical suite notes documentation on a client's medical record that they have a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?
A nurse in a surgical suite notes documentation on a client's medical record that they have a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?
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A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate?
A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate?
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A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next?
A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next?
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A nurse is caring for a client who is scheduled to be transferred to a long-term care facility. The client's family questions the nurse about the reasons for the transfer. Which of the following responses made by the nurse is appropriate?
A nurse is caring for a client who is scheduled to be transferred to a long-term care facility. The client's family questions the nurse about the reasons for the transfer. Which of the following responses made by the nurse is appropriate?
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A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?
A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?
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A nurse is caring for a client who is having difficulty breathing. The client is supine and is receiving supplemental oxygen via a nasal cannula. Which of the following interventions should the nurse take first?
A nurse is caring for a client who is having difficulty breathing. The client is supine and is receiving supplemental oxygen via a nasal cannula. Which of the following interventions should the nurse take first?
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A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?
A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?
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A nurse is caring for a client who is postoperative. When the nurse prepares to change the client's dressing, they say, "Every time you change my bandage, it hurts so much." Which of the following interventions is the nurse's priority action?
A nurse is caring for a client who is postoperative. When the nurse prepares to change the client's dressing, they say, "Every time you change my bandage, it hurts so much." Which of the following interventions is the nurse's priority action?
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A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching they received about pain management?
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching they received about pain management?
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A client who is nonambulatory notifies the nurse that their trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next?
A client who is nonambulatory notifies the nurse that their trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next?
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A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?
A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?
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A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?
A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?
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A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?
A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?
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A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate?
A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate?
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A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
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A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?
A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?
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A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include?
A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include?
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A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client?
A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client?
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A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care?
A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care?
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A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make?
A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make?
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A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
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A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? (Select all that apply.)
A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? (Select all that apply.)
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