A charge nurse has four new clients arriving on the unit for admission. Which of the following clients should the nurse place in airborne precautions?

A nurse is considering placing wrist restraints on a client who has cognitive deficits and has pulled out their IV catheter. Before using wrist restraints, which of the following actions must the nurse take first?

A nurse is administering a medication to a client. The nurse identifies the client has an allergy to the medication after it has been administered. Which of the following actions should the nurse take?

A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?

A nurse is administering multiple types of ophthalmic drops to a client. Which of the following actions should the nurse take?

A nurse is preparing to collect a sputum specimen from a client. Which of the following actions should the nurse take?

A nurse is preparing to transfer a client to the radiology department using a wheelchair. Which of the following actions should the nurse take?

A nurse is caring for a client who is scheduled for an appendectomy.

Exhibit 1 Exhibit 2 Exhibit 3

Nurses' Notes

1050:

Received handoff report from the ED nurse for a client who has acute appendicitis and is scheduled for an appendectomy. Client reports that pain began in the midabdominal region during the night. This morning the pain intensified and localized to the right lower quadrant region. Pain continues to intensify. rebound tenderness noted. Reports vomiting one time after eating a piece of toast at 0600 with continued feelings of nausea.

Peripheral IV to the left forearm with IV fluids infusing.

1200:

Informed consent obtained by the surgeon performing the procedure. Placed in the client's medical record. Client expressing concern about potential complications that could result from the surgery.

Medical History

1050:

Received influenza vaccine 1 month ago.

Thyroid disease, taking levothyroxine for 14 years. History of cholecystectomy 3 years ago.

Denies alcohol or illegal drug use. Reports smoking approximately 6 cigarettes per day for the past 10 years. Allergic to shellfish, latex, and penicillin.

Vital Signs

0945, Upon admission to emergency department (ED): Temperature 38.3°C(100.9° F)

Pulse rate 102/min Respiratory rate 22/min

Blood pressure 122/80 mm Hg Oxygen saturation 96% on room air Pain reported as 6 on a scale of 0 to 10.

1050, Upon admission to medical-surgical department Temperature 38,4° C (101.2° F)

Pulse rate 104/min Respiratory rate 22/min

Blood pressure 124/80 mm Hg Oxygen saturation 96% on room air Pain reported as 8 on a scale of 0 to 10

The nurse is preparing the client for surgery. Select the 4 findings that require follow-up prior to surgery.

A nurse is assessing a client whose therapy has included bed rest for several weeks.
Which of the following findings should the nurse identify as the priority?

A nurse is assessing a client who has hypocalcemia. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is teaching a client about logrolling while in bed. Which of the following information should the nurse include in the teaching?