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

A client recovering from surgery sits in a chair for breakfast. Which action does the nurse take before applying newly prescribed anti-embolism stockings to the client's lower extremities?

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 provides care for a client recovering from a motor vehicle crash. For which sign of fluid volume overload does the nurse measure the client's intake and output? (Select all that apply)

The nurse provides care for a patient with an infected surgical wound. The nurse assesses the wound and changes the dressing. Which does the nurse include in the documentation? Select all that apply.

The nurse provides care for a client having an incisional biopsy of a skin lesion. Which teaching about the care of the site does the nurse provide to the client?

The nurse is caring for a client with a diagnosis of a ruptured appendix who underwent an emergency exploratory laparotomy with appendectomy 48 hours ago. The 55-year-old client was admitted through the Emergency Department (ED) with fever, chills, nausea, and diffuse abdominal pain. Computed tomography (CT) of the abdomen confirmed a ruptured appendix with widespread inflammation. The client is 6'4" (193.04 cm) tall and weighs 260 lbs (117.93 kg). The client is obese with a BMI of 31.6 kg/m2. The client underwent an immediate exploratory laparotomy with appendectomy. The wound was not closed and was packed with sterile gauze.

Past Medical History (PMH) includes gastric reflux disease (GERD), hypertension, and type 2 diabetes mellitus. The client has no known drug allergies (NKDA). Home medications include:

1. Lisinopril 20 mg, 1 tablet PO every day
2. Omeprazole 40 mg, 1 capsule PO every day
3. Metformin ER (extended-release) 750 mg, 1 tablet PO every day
4. Acetaminophen 325 mg, 2 tablets PO every 4 hours PRN

The nurse medicates the client for pain prepares to irrigate the wound and completes the dressing change. The nurse observes a gush of fluid and sees a small portion of the client's intestine protrude from the wound bed. What actions does the nurse take immediately?

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

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?

A client diagnosed with a bilateral hearing impairment seeks medical attention for an acute health problem. Which approach does the nurse use to enhance communication with this client?

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