A nurse in an emergency department is caring for a child who reports being sexually abused by a family member. Which of the following actions should the nurse take?

A nurse is caring for a 2-year-old toddler. Which of the following food choices should the nurse recommend to promote independence in eating?

A nurse is caring for a client who is postoperative following a right hip arthroplasty.

Vital Signs

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1330:

Temperature 36.8° C (98.2° F) Heart rate 88/min

Respiratory rate 16/min BP 110/64 mm Hg

Oxygen saturation 96% on oxygen 3 U/min via simple face mask 1345:

Temperature 37° C (98.6" F) Heart rate 112/min Respiratory rate 20/min

BP 108/60 mm Hg

Oxygen saturation 94% on oxygen 3 L/min via simple face mask 1400

Temperature 38.3° C (101° F) Heart rate 152/min Respiratory rate 26/min

BP 90/54 mm Hg

Oxygen saturation 89% on oxygen 4 Umin a simple face mask

For each assessment finding, specify if the finding is consistent with malignant hyperthermia, latex allergy, or hypovolemic shock. Each finding may support more than 1 disease process

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Vital signs include: heart rate 122 beats/minute, respiratory rate 28 breaths/minute, and blood pressure 170/90 mmHg.

Which assessment finding warrants the most immediate intervention by the nurse?

A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take?

A nurse is reviewing the medical records of four clients. The nurse should identify which of the following client findings that requires follow-up care.

A nurse is assisting with food selection for a client who follows kosher dietary traditions. Which of the following food choices should the nurse include on the client's food tray?

A nurse is providing teaching about the use of crutches using a three-point gait to a client who has a tibia fracture. Which of the following actions by the client indicates an understanding of the teaching?

A nurse is teaching a class about providing care within the legal scope of practice to a group of nurses.
The nurse should include that which of the following procedures is outside the legal scope of practice for an RN?

A nurse is caring for a client in a clinic.

Vital Signs 0915:

Temperature 36.7° C (98° F)

BP 122/80 mm Hg Respiratory rate 20/min Heart rate 99/min

Nurses' Notes 0900:

A 16-year-old client reports to the clinic with their caregiver. The client's caregiver informs the nurse that the client has "not been themselves lately." The client's parents and a sibling passed away from injuries sustained when a tornado moved through their town 1 month ago. They were the only survivors and witnessed their family's deaths.

0910:

The client appears anxious but answers appropriately for age. They report experiencing nightmares that awaken them at night and startle easily during thunderstorms, but the client admits that they have always been afraid of thunderstorms. The client admits to smoking marijuana for about 1 month because it helps clear their mind. They also admit that they have no desire to leave the house. They attend school regularly and are on the honor roll.

Based on the information in the client's medical record, which of the following findings requires immediate follow-up?

Select the 4 findings that require follow-up.