A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices." Which of the following responses is the priority for the nurse to state?

A nurse is caring for a client who has a prescription for lactated Ringer's IV 4,080 mL/24 hr. The nurse should set the IV infusion pump to deliver how many mL/hr to administer half the total volume in the first 8 hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is teaching a client who has rheumatoid arthritis about illness management. Which of the following instructions should the nurse include in the teaching?

A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse should recognize which of the following findings as an indication that the medication has been effective?

The nurse continues to care for the client.

Highlight the findings that indicate improvement in the client's condition. To deselect a finding

A nurse is preparing to administer levothyroxine 50 micrograms to a client. Available is levothyroxine 0.025 mg/tablet. How many tablets should the nurse administer per dose?
(Round 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.

Nurses' Notes 0900:

Client reports a 3-month history of intermittent diarrhea and abdominal pain. Reports unintentional weight loss of 5.5 kg (12 lb) in 3 months.

0930:

Stool sample obtained for fecal occult blood test. Fatty appearance and foul odor noted.

For each assessment finding, click to specify if the finding is consistent with ulcerative colitis, diverticulitis, or Crohn's disease. Each finding may support more than 1 disease process.

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.

A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr. Which of the following interventions should the nurse anticipate?

The nurse reviews the entries in the medical record.

Admission Assessment 0900:
Client reports, "I'm bloated and my stomach hurts." History of prior illness: Client reports a 3-week history of gnawing abdominal pain. Client states, "It's a burning sensation that radiates to my back. I think I've lost a little weight too." Reports one episode of dark, tarry stool. No vomiting. Client reports pain is worse about 1 hr after eating a meal. Past medical history: Osteoarthritis
Social history: Recently divorced, drinks in moderation (3 to 4 drinks per week), smokes tobacco
Current medications:

Ibuprofen 800 mg three times daily PRN arthritis pain Physical Examination:

General: client appears uncomfortable, diaphoretic

Head, ears, eyes, nose, and throat (HEENT): oropharynx clear, mucous membranes moist and pale
Respiratory: bilateral breath sounds clear

Gastrointestinal: epigastric tenderness to palpation, no rebound tenderness or guarding Neurological: oriented x 3 (person, place, and time)

The nurse is ready to begin. For each potential nursing action, specify if the action is indicated or not indicated for the client.
Nursing Actions