A charge nurse in a long-term care facility notices the smell of alcohol on a nurse's breath.

Which of the following actions should the nurse take first?

A nurse is assisting in the care of a client. Nurses' Notes 2000:

Client presents to emergency department and states, "I have been assaulted." Client was immediately placed in a treatment room.

2015:

"Client states they were out with friends this evening and had "a little too much to drink." Client states that they fell asleep at their friend's house and when they woke up all of their clothes were off and their genitals were sore. The client states, "I think someone had sex with me, but I don't remember anything." Client reports history of depression. Client is a full-time college student who lives with roommates. Client admits to drinking socially but denies illicit drug use and tobacco use.

Which of the following interventions should the nurse plan to implement?

Select all that apply.

A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?

A nurse is reinforcing teaching with a client who has a new prescription for enoxaparin. The nurse should identify which of the following over-the- counter products as unsafe for use with enoxaparin?

Read the information below.

• Client reports pain at surgical incision site as 5 on a scale of 0 to 10.
• Client reports bladder fullness. Perineal dressing intact with minimal serosanguinous drainage.
• Client transferring out of bed to chair independently.
• Extremities cool and dry with 2+ peripheral pulses.
• Client reports abdominal cramping and small, hard, painful bowel movement after lunch.
• Ambulating independently in hallway.
• Reports pain as 8 on a scale of 0 to 10, Urinary catheter intact with 100 mL/hr of pink urine.

A nurse is reinforcing teaching with a client who is taking allopurinol about the risk for developing Stevens-Johnson syndrome.

For which of the following manifestations should the nurse instruct the client to monitor and report?

A nurse is supervising an assistive personnel (AP) who is applying antiembolic stockings for a client. Which of the following actions by the AP requires intervention by the nurse?

A nurse is reinforcing teaching with a client who has a new prescription for epinephrine auto-injector PRN. The nurse should reinforce with the client that the medication can help treat which of the following manifestations?

A nurse is reinforcing teaching about disease management with a client who has GERD.

Which of the following statements should the nurse make?

A nurse is caring for a client who is 1 day postoperative following a total hip arthroplasty and is receiving heparin subcutaneously.

Which of the following adverse effects of the medication should the nurse report to the provider?

A nurse is collecting data from a client during a routine prenatal visit. The client is in their second trimester of pregnancy and reports feeling dizzy, has a racing heart, and becomes pale while lying on their back.

Which of the following actions should the nurse take?