A nurse is caring for a client in a clinic.

Vital Signs 0915:

Temperature 36.7° C (98° F)

BP 122/80 mm Hg Respiratory rate 20/min Heart rate 99/min

Nurses' Notes 0900:

A 16-year-old client reports to the clinic with their caregiver. The client's caregiver informs the nurse that the client has "not been themselves lately." The client's parents and a sibling passed away from injuries sustained when a tornado moved through their town 1 month ago. They were the only survivors and witnessed their family's deaths.

0910:

The client appears anxious but answers appropriately for age. They report experiencing nightmares that awaken them at night and startle easily during thunderstorms, but the client admits that they have always been afraid of thunderstorms. The client admits to smoking marijuana for about 1 month because it helps clear their mind. They also admit that they have no desire to leave the house. They attend school regularly and are on the honor roll.

Based on the information in the client's medical record, which of the following findings requires immediate follow-up?

Select the 4 findings that require follow-up.

Client reports to clinic for monthly prenatal visit. Client is at 20 weeks of gestation. Since last visit, client reports concern about the occurrence of intermittent mild backaches, increased heartburn, generalized itching, and vaginal discharge. Which one of the following statements should the nurse include in the clients teaching? Select all that apply

A nurse is caring for a client who is postoperative following a right hip arthroplasty.

Vital Signs

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1330:

Temperature 36.8° C (98.2° F) Heart rate 88/min

Respiratory rate 16/min BP 110/64 mm Hg

Oxygen saturation 96% on oxygen 3 U/min via simple face mask 1345:

Temperature 37° C (98.6" F) Heart rate 112/min Respiratory rate 20/min

BP 108/60 mm Hg

Oxygen saturation 94% on oxygen 3 L/min via simple face mask 1400

Temperature 38.3° C (101° F) Heart rate 152/min Respiratory rate 26/min

BP 90/54 mm Hg

Oxygen saturation 89% on oxygen 4 Umin a simple face mask

For each assessment finding, specify if the finding is consistent with malignant hyperthermia, latex allergy, or hypovolemic shock. Each finding may support more than 1 disease process

A nurse is caring for a client who has given informed consent for electroconvulsive therapy. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate?

A nurse is teaching a client who has a new diagnosis of diabetes mellitus about foot care.

Which of the following instructions should the nurse include in the teaching?

A nurse is preparing to administer levothyroxine 50 micrograms to a client. Available is levothyroxine 0.025 mg/tablet. How many tablets should the nurse administer per dose?
(Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is caring for a client who has been admitted to the antepartum unit.

History and Physical Day 1,0900:

30-year-old client at 33 weeks gestation, Gravida 4 Para 3 Maternal blood type: Rh+

Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks gestation. Nurses' Notes

Day 1, 0900:

Client reports lower back pain and pinkish vaginal discharge.

Uterine contractions every 8 minutes, palpate strong, duration 30 seconds. FHR baseline 145, minimal variability.

Cervical exam indicates 2 cm, 50% effaced, 0 station. Membranes intact.

CBC and urinalysis collected and sent to lab.

Highlight the findings that require follow-up.

A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make?

A nurse is caring for a client whose partner recently died. The nurse sits with the client to provide comfort. Which of the following ethical principles is the nurse demonstrating?

A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr. Which of the following interventions should the nurse anticipate?

A nurse is providing discharge teaching to the partner of a client who has a tracheostomy. Which of the following information should the nurse include in the teaching?