A nurse is assisting a postoperative client.

The client is alert and oriented to person, place, and time, and reports incisional pain of 9 on a scale of 1 to 10. Morphine 8 mg was administered subcutaneously as prescribed at 0900.

The client is now sleeping and is difficult to arouse.

Pupils are 3 mm, equal and reactive to light.

Temperature is 37.5 C (99.5°), respirations are 10/min, and pulse oximetry is 87% on room air.

Which documentation in the client’s medical record requires further action by the nurse?

The nurse is caring for an 85-year-old patient with septic shock.

What should the nurse consider when repositioning this patient?

A client with a spinal cord injury is at risk for experiencing autonomic dysreflexia.

Which of the following manifestations should the nurse carefully monitor the client for?

A nurse is attending to a client who has suffered a basal skull fracture.

During the morning hygiene care, the nurse observes a thin clear drainage coming from the client’s right nostril.

What should be the nurse’s immediate action?

The nurse is instructing a patient on how to administer 0.5 mg of epinephrine intramuscularly.

If the available dose is 0.5 mg/0.5 mL, how many mL should the patient be taught to administer?

A nurse is assisting a postoperative client.

The client is alert and oriented to person, place, and time, and reports incisional pain of 9 on a scale of 1 to 10. Morphine 8 mg was administered subcutaneously as prescribed at 0900.

The client is now sleeping and is difficult to arouse.

Pupils are 3 mm, equal and reactive to light.

Temperature is 37.5 C (99.5°), respirations are 10/min, and pulse oximetry is 87% on room air.

Which documentation in the client’s medical record requires further action by the nurse?

A nurse is caring for a patient admitted with a lower respiratory infection.

After assisting the patient to bed and applying the prescribed oxygen, which finding would help the nurse evaluate the effectiveness of the nursing care?

The nurse is performing pin care for a patient with an external fixation device for a fractured tibia.

Which assessment finding by the nurse should be reported to the unit care coordinator?

A nurse is providing care for a client with severe burns.

The client’s vital signs at 0820 are as follows: Blood pressure 140/80 mm Hg, Heart rate 110/min, Respiratory rate 25/min, Sa 98% on room air, Temperature 36.1 C (97° F). Which of the following interventions should the nurse consider? (Select all that apply.)

A nurse is educating a client newly diagnosed with hepatitis C. Which statement from the nurse best describes how the virus is transmitted?

A patient is unresponsive to verbal stimuli and exhibits an altered level of consciousness.

Which method should the nurse use to elicit a response from a painful stimulus?