A client receives a clear liquid diet. The nurse removes which item from the client's tray? (Select all that apply)

The nurse plans care for a client who reports avoiding people because of having scabies and difficulty walking. Which statement does the nurse document as the client's greatest concern?

A bed-bound chart has a prescription for routine urinalysis. In which way does the nurse obtain the urine sample for the laboratory?

The emergency department (ED) triage nurse receives a report from emergency medical services (EMS) on an older adult client being brought to the ED via EMS. After receiving the report, the nurse reviews the client's electronic medical record (EMR) for history and the most recent medication list.

The client was transferred to ED Bed 5 via stretcher. The client’s spouse is at the bedside. The client states "I feel so much better now except my wrist. It's really hurting." Advised to assess and then check with ED physician about something for the pain. VS BP 112/68 HR 99 RR 20. T 98.4° F (36.9° C). SpO2 96% on room air. The client is alert and oriented (A&O x 4), pleasant, and cooperative. PERRLA, skin intact with no bruising except for dorsal left forearm and wrist which is ecchymotic and edematous. Radial pulses are strong and equal (+3). Fingers warm with capillary refill - 3 sec. Lungs clear Abdomen soft with bowel sounds x 4 quadrants. Pedal pulse + x 4 and no pedal edema.

The client is being prepped for an open reduction internal fixation of the left wrist on the morning of day 2.

> Which three findings indicate that the client’s hemodynamic status has improved?

In which situation is the nurse determined to be negligent?

The nurse instructs the client on the use of an incentive spirometer. Which observation indicates to the nurse that additional teaching is required?

The nurse delegated vital signs for a group of patients to the unlicensed assistive personnel (UAP). Which client condition would prohibit having a rectal temperature taken by the UAP?

The nurse omits to document an assessment finding that resulted in a significant client injury. For which legal issue does the nurse need to prepare?

The nurse is caring for a senior adult client with three diagnoses of Parkinson's disease and an exacerbation of COPD. The nurse observes the unlicensed assistant personnel (UAP) providing morning care and obtaining vital signs by using a portable electronic blood pressure cuff and clip-on pulse oximetry sensor.

Nurse's Notes: Vital Sign # 0715: Client sitting up in bed with oxygen 2.1 per nasal cannula (NC) on. Clear pink skin and warm and dry lungs with scattered wheezes throughout. The client complains of shortness of breath and states, "I feel so much better than I did a couple of days ago." Mild tremors were noted. The client states, "My hands shake all the time."

1140: Client is still in bed with oxygen 2.1 per NC on, scattered wheezes throughout, and coarse rhonchi, which are clear with coughing. Cough is productive of yellow phlegm. Skin cool and dry. The client complains of shortness of breath or discomfort and states, "I like to keep it chilly in my room to help me breathe."

1140: The UAP reports to the nurse that the client's SpO2 is decreased.

Q1. After assessing the patient and reviewing the vital signs, which nursing action is appropriate to address the decreased SpO2?

(Select all that apply.)

A family member tells the nurse, "I overheard a caregiver threaten my uncle." The family member said the caregiver remarked, "If you don't learn to calm down, I will have to restrain you." Based on this information, which criminal offense does the nurse communicate to the nurse manager?

While the nurse prepares an injection for a client, the needle cap falls on the floor. Which action indicates that the injection will be sterile?