A nurse in a walk-in clinic is caring for a client.

Which of the following six findings should the nurse report to the provider? Select the 6 findings that require immediate follow-up.

1300:

• Temperature 39.1° C (102.4° F)
• Heart rate 115/min
• Respiratory rate 30/min
• Blood pressure 99/58 mm Hg
• Oxygen saturation 93% on room air

1330:

• Temperature 39.2° C (102.5° F)
• Heart rate 118/min
• Respiratory rate 28/min
• Blood pressure 91/52 mm Hg
• Oxygen saturation 95% on 2 L/min nasal cannula
• Heart rate
• Skin turgor
• Temperature
• Heart sounds
• Blood pressure
• COVID test results
• Orientation
• Lung sounds

A charge nurse in a long-term care facility is preparing an educational program about delirium for newly hired nurses. Which of the following statements should the nurse plan to include?

A nurse in a health clinic is caring for a client.

Click to highlight the findings that the nurse should report to the provider. To deselect a finding, click on the finding again.

Nurse's Notes and Diagnostic Results

Vital Signs 0930:

• Temperature: 39.3° C (102.8° F)
• Heart rate: 113/min
• Respiratory rate: 24/min
• Blood pressure: 122/68 mm Hg
• Oxygen saturation: 96% on room air

Nurses' Notes 0930:

• Client reports 2-day history of urinary frequency, burning on urination, and lower back and suprapubic pain. States developed a fever this morning.
• Oriented x 4, answers questions appropriately.
• S1, S2 on auscultation. Lungs clear on auscultation.
• Bowel sounds x 4 quadrants active, denies nausea or vomiting.

Diagnostic Results 1030:

• Urinalysis:
  • Appearance: cloudy (clear)
  • Colour: cloudy (amber yellow)
  • Odour: foul (aromatic)
  • pH: 8.0 (4.6 to 8.0)
  • Protein: 6.5 mg/dL (0 to 8 mg/dL)
  • Specific gravity: 1.035 (1.005 to 1.030)
  • Leukocyte esterase: positive
  • Nitrites: present
  • Ketones: none (none)
  • Bilirubin: none (none)
  • Crystals: none (none)
  • Casts: none (none)
  • Glucose: none (none)
  • White blood cells: 8 (0 to 4)
  • Red blood cells: 3 (less than 2)

A nurse is performing postural drainage with percussion and vibration for a client who has cystic fibrosis. Which of the following actions should the nurse take?

A nurse is providing teaching for a client who is scheduled for an allogeneic stem cell transplant. Which of the following information should the nurse include?

A nurse in a walk-in clinic is caring for a client.

Which of the following six findings should the nurse report to the provider? Select the 6 findings that require immediate follow-up.

1300:

• Temperature 39.1° C (102.4° F)
• Heart rate 115/min
• Respiratory rate 30/min
• Blood pressure 99/58 mm Hg
• Oxygen saturation 93% on room air

1330:

• Temperature 39.2° C (102.5° F)
• Heart rate 118/min
• Respiratory rate 28/min
• Blood pressure 91/52 mm Hg
• Oxygen saturation 95% on 2 L/min nasal cannula
• Heart rate
• Skin turgor
• Temperature
• Heart sounds
• Blood pressure
• COVID test results
• Orientation
• Lung sounds

A nurse is preparing to administer a controlled substance to a client for pain management. Which of the following actions should the nurse take?

A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing the client's signature, the client states, "I trust my doctor, but I don't understand what is meant by resecting my intestines." Which of the following actions should the nurse take?

A nurse is caring for a client who refuses to follow the provider's prescription for strict bed rest. The nurse overhears an assistive personnel (AP) telling the client, "If you do not remain in bed, I will place you in restraints." The nurse should identify that the AP is committing which of the following torts?

A nurse is preparing to insert an IV catheter for an adult client. Which of the following actions should the nurse take?

A nurse is planning care for a client who has a latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the client's plan of care?