A home health nurse is performing a fall risk assessment for an older adult client. Which of the following findings should the nurse identify as a potential fall risk in the home?

A nurse is providing information to a client about durable power of attorney. The nurse should include that durable power of attorney is enforceable under which of the following conditions?

A nurse is caring for a client who has recently retired from their job. The client states they feel like they no longer have a purpose. Which of the following responses should the nurse make?

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

A home health nurse is performing a fall risk assessment for an older adult client. Which of the following findings should the nurse identify as a potential fall risk in the home?

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 assessing a client's cranial nerve VII. Which of the following responses should the nurse expect?

A nurse is administering an intramuscular injection to a client using the Z-track method.
Which of the following actions should the nurse take?

A nurse is preparing to administer cefoxitin 80 mg/kg/day IV every 6 hr to a 6-year-old child who weighs 20 kg. How many mg should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

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 3 findings that require follow-up prior to surgery.

A nurse is planning to use nonpharmacological pain relief methods for a client who reports continued mild back pain after receiving analgesia 1 hr ago. Which of the following actions should the nurse include in the plan?