A nurse is caring for a client.

Exhibits

A nurse is continuing care for the client.

For each potential nursing action, click to specify if the nursing action is anticipated or contraindicated for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.

A nurse is caring for a client.

Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

Nurses' Notes

0900:

Client who is at 38 weeks of gestation presents to the antepartum unit with uterine contractions, dark red vaginal bleeding, and abdominal pain that started approximately 45 min prior to arrival. Rates abdominal pain a 7 on a scale of 0 to 10. Client reports, "My blood pressure has been high during the pregnancy."

Home Medications: prenatal multivitamin, methyldopa 250 mg PO twice daily Physical Exam:

General: tearful, anxious

Cardiovascular: S1, S2, no murmur

Respiratory: bilateral breath sounds clear

Abdomen: Uterine hypertonicity with a board-like abdomen, tenderness noted upon palpation of left upper quadrant

FHR: 116/min, minimal variability noted

A nurse working in the emergency department (ED) is admitting a client.

Click to highlight the findings that indicate the client is progressing in their plan of care. To deselect a finding, click on the finding again.

To deselect a finding, click on the finding again.

Nurses' Notes

Day 4, 1030:

Client states, "It is easier to breathe and I'm not as short of breath." Lung sounds still diminished with crackles. No wheezes detected. Client is on oxygen at 1 U/min via nasal cannula and oxygen saturation is 92%. Client reports pleuritic chest pain as 3 on a scale of 0 to 10. Cough is productive and sputum is yellow. Drinking 2 L per day. Voided 200 ml of clear yellow urine.

A nurse is caring for a 9-year-old child at a clinic.

The nurse reviews the assessment findings.

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Assessment

Respirations easy and unlabored. Abdomen non-distended. Right forearm and fingers are edematous. Ecchymotic area noted on outer aspect of the forearm. Radial pulse +2. Fingers slightly cool to touch. Child can move fingers and reports a mild "tingling" sensation. Child verbalizes a pain level of 4 on a scale of 0 to 10. Multiple areas of bruising are noted on lower extremities in various stages of healing.

Vital Signs

Temperature 36.8° C (98.2° F)

Heart rate 102/min Respiratory rate 22/min

BP 100/60 mm Hg

Oxygen saturation 98% on room air

A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu. The nurse should recognize which of the following findings as a potential contraindication for using lavender?

A nurse is providing discharge teaching to a client following a total gastrectomy. The nurse should instruct the client about which of the following medications?

A nurse is teaching a client about advance directives. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is planning care for a client who sustained a major burn over 20% of the body. Which of the following interventions should the nurse include to support the client's nutritional requirements?

A nurse working in the emergency department (ED) is admitting a client.

The nurse is preparing the client for a thoracentesis. Select the 4 actions that the nurse should take.

A nurse is obtaining the temperature of a newborn. Which of the following sites should the nurse use?

A nurse is caring for a 9-year-old child at a clinic.

The nurse should determine that the assessment findings are consistent with which of the following conditions?

For each potential condition, click to specify if the assessment findings are consistent with a sprain, a fracture, or a dislocation. Each finding may support more than 1 condition.