A nurse is assisting with the plan of care for a client who is in the third trimester of pregnancy and has ankle edema. Which of the following interventions should the nurse include in the client's plan of care?

A nurse is providing site care for a child who has a gastrostomy enteral tube. Which of the following actions should the nurse take?

A nurse is suctioning the airway of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following findings should the nurse identify as an indication that the suctioning has been effective?

A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding. The nurse speaks a different language than the client. The client's partner and 10-year-old child are accompanying her. Which of the following actions should the nurse take to gather the client's admission data?

A nurse is contributing to an in-service for newly licensed nurses about situations requiring an incident report. Which of the following examples should the nurse include?

A nurse is collecting data from a client. The nurse should identify that which of the following manifestations is an indication of a candida infection?

A nurse is monitoring a client who has received external radiation for throat cancer. Which of the following findings should the nurse expect?

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 reinforcing teaching with a client who has Crohn's disease. Which of the following statements by the client indicates an understanding of the teaching?

A nurse enters the room of a school-age child and finds them on the floor experiencing a tonic-clonic seizure. Which of the following action should the nurse take?

A nurse is updating the plan of care for a client who has amyotrophic lateral sclerosis with dysphagia. Which of the following interprofessional team members should the nurse identify as the priority to consult?