A nurse is assessing a client who is receiving continuous IV fluids through a peripheral IV. Which of the following findings indicates to the nurse that the client is experiencing fluid overload?

A nurse is caring for a client who has chronic back pain and asks about receiving acupuncture for relief. Which of the following findings should the nurse identify as a contraindication to receiving this treatment?

A nurse is providing preoperative teaching to a client over the phone in preparation for outpatient surgery. Which of the following information should the nurse include in the teaching?

A nurse is planning care for a client who has a prescription for extremity restraints on both wrists. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

A nurse is providing teaching to a client who is to self-administer an ophthalmic solution. Which of the following statements by the client indicates an understanding of the teaching?

A nurse at a long-term care facility is providing change-of-shift report to an oncoming nurse about a client who has shingles. Which of the following information should the nurse include in the report?

A nurse is caring for a client who is agitated and threatening to harm others. The nurse places the client in restraints but does not notify the provider or obtain a prescription for the restraints. This situation represents which of the following torts?

A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is caring for a client who has an ileostomy.
Nurses' Notes
Day 1:

• Client is alert and oriented.
• ileostomy stoma is pink.
• Stoma draining moderate brown liquid stool.
• Client will not look at the stoma.
• Client states they are not interested in learning about stoma care.
• Intake: 2,200 mL over the last 24 hr
• Urine output: 1,200 ml over the last 24 hr

Day 2:

• ileostomy pouch changed. Skin surrounding the stoma is reddened and appears irritated
• initiated a request for a referral to an ostomy nurse.
• intake. 1,600 mL over the last 24 hr
• Urine output: 650 mL over the last 24 hr

The nurse is reviewing the client's medical record. Select the information that requires intervention by the nurse.

A nurse is caring for a client who is nauseated and unable to eat after taking an antibiotic. Identify the steps the nurse should take to address the client's nausea.

(Arrange the steps, placing them in the order of performance. Use all the steps.)

A nurse is monitoring a client who is receiving continuous IV fluid therapy via a peripheral vein in the left forearm. Which of the following findings indicates that the client has developed phlebitis at the IV site?