A nurse is assisting with the care of a client who is receiving a PCA pump following a hysterectomy. Which of the following findings should the nurse identify as an indicator of unrelieved pain?

A nurse is reinforcing discharge teaching with a client who has undergone a vein stripping of the right leg. Which of the following instructions should the nurse include in the teaching?

A nurse is reinforcing teaching with a client who has a new diagnosis of COPD. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is performing a skin assessment on a client who has a dark skin. Which one of the following locations on the client’s body should the nurse observe to access for jaundice?

A nurse is reviewing the medical record of a client. These are the medical reports; Hypoactive bowel sounds upon auscultation, abdomen soft, not distended on palpation and urinary output of 130mL/4hr. Which of the following findings should the nurse report to the provider?

A nurse is caring for a client who has schizophrenia and is taking an antipsychotic medication. Which of the following screening tools should the nurse use to identify tardive dyskinesia?

A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following findings is the nurse's priority?

A nurse is reinforcing teaching with a new mother about facility security measures. Which of the following statements by the mother indicates an understanding of the teaching?

The nurse is assisting in the care of the client who is at 30 weeks of gestation.

Nurses' Notes

1200:

Provided a quiet environment, dimmed the lights, and encouraged client to remain in bed in the side-lying position.

Encouraged client to cough and take deep breaths regularly.

Assisted with insertion of 18-gauge IV and initiation of IV fluid.

Assisted with insertion of indwelling urinary catheter per provider prescription. Maintained strict input/output monitoring; total intake 180 mL/hour.

FHR 136/min via external fetal monitor. Minimal variability noted, no contractions present.

1400:

Magnesium sulfate infusion ongoing.

Client is lethargic. Heart rate regular 58bpm, blood pressure 148/99 mmHg, respirations shallow DTR 1+ bilaterally.

Urine output 20 mL in the last hour

1405:

Assists with discontinuation of magnesium sulfate infusion Notifies provider of client status.

1800:

Client is alert and responsive. Heart rate regular 78bpm, respirations even and unlabored. DTR 2+ bilaterally

Oxygen saturation (SaO) 95% on 2 L nasal cannula. Respiratory rate 18/min. Blood pressure 146/96 mm Hg.

Select the findings that indicate the client's condition has improved.

A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect?

A nurse is reinforcing teaching with a client about intermittent catheterization to measure residual urine. Which of the following information should the nurse include in the teaching?