A nurse is caring for a client.

Vital Signs

0800:

• Temperature 37.6° C (99.7° F)
• Blood pressure 108/56 mm Hg
• Heart rate 66/min
• Respiratory rate 18/min
• Pulse oximetry 97% on room air

0830:

• Temperature 37.5° C (99.5° F)
• Blood pressure 88/56 mm Hg
• Heart rate 104/min
• Respiratory rate 24/min
• Pulse oximetry 93% on room air

Select the 4 findings that require immediate follow-up.

A nurse is caring for a client who has a tracheostomy.

Which of the following actions should the nurse take?

A nurse is preparing to administer an injection to a client.

Which of the following actions should the nurse plan to take after administering the injection?

A nurse is caring for a client who has a prescription for a 250 mL IV fluid bolus. The nurse administers a 500 mL IV bolus.

Which of the following actions should the nurse take first?

A community health nurse is teaching a group of clients about Kegel exercises to prevent urinary incontinence.

Which of the following instructions should the nurse include?

A nurse is preparing to insert an IV catheter for a client following a right mastectomy.

Which of the following veins should the nurse select when initiating IV therapy?

A nurse is planning care for a female client who has an indwelling urinary catheter.

Which of the following actions should the nurse include in the plan?

A home health nurse is teaching a client about home safety.

Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.).

A nurse is preparing to administer medication to a client. Which of the following should the nurse use as a client identifier?

A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing the client's signature, the client states, "I trust my doctor, but I don't understand what is meant by resecting my intestines."

Which of the following actions should the nurse take?