A nurse is assisting in the care of a client who is in the emergency department (ED) following a ski accident.

Exhibits

The nurse is collecting data on the client. Which of the following findings require follow up?

Select all that apply.

A nurse is reinforcing teaching with a client who is to undergo a bone marrow aspiration. Which of the following statements should the nurse include in the teaching?

A nurse is transporting a client who has pneumonia and is on droplet precautions to radiology. Which of the following safety measures should the nurse take while transporting the client?

A nurse is assisting in the care of the client who is postoperative following a fasciotomy.

The nurse is reviewing the client's electronic medical record (EMR). Click to highlight the statements in the EMR that indicate the client's condition is improving since implementing interventions. To deselect a finding, click on the finding again

Nurses' Notes

Day 3, 2300:

Client is alert and oriented to person, place, and time. Bilateral breath sounds clear and present throughout. Right leg with splint in place. Incisional dressing dry and intact. Wound drain to negative-pressure vacuum, draining small amounts of serosanguinous fluid. Bilateral pedal pulses 3+. Feet warm with intact movement and sensation. Client reports pain as a 4 on a scale of 0 to 10.

Vital Signs

Day 3, 2300:

Temperature 37.8° C (100° F)

Blood pressure 120/58 mm Hg

Heart rate 98/min

Respiratory rate 20/min

Oxygen saturation 95% on room air

A nurse is contributing to the plan of care for a client following a total hip arthroplasty. Which of the following interventions should the nurse recommend?

A nurse is assisting with the plan of care for a client who has aspiration pneumonia and hypoxia. Which of the following actions should the nurse plan to take?

A nurse is preparing to administer warfarin to a client who has chronic atrial fibrillation. Which of the following laboratory values should the nurse monitor prior to administering the medication?

A nurse is assisting in the care of a client who is postoperative following an open reduction internal fixation of the right tibia.

For each finding, click to specify if the finding is consistent with acute compartment syndrome, infection, and/or fat embolism syndrome. Each finding might support more than 1 disease process.

A nurse is assisting with the care of an 18-year-old client who is at their provider's office for an annual physical. The client inquires about cancer examinations that they should have. Which of the following examinations should the nurse recommend?

A nurse in an assisted living facility is collecting data from an older adult client who fell in their room and hit their head on the dresser. Which of the following findings is the nurse's priority?

A nurse is collecting data from a client who has a newly placed colostomy. Which of the following findings should indicate to the nurse the client has accepted their new altered body image?