A nurse is caring for a client in the emergency department.

Exhibits here

Click to highlight the findings that indicate that the client's condition is improving. To deselect a finding, click on the finding again.

1400:

Client admitted to the medical-surgical unit at 1200 today. Alert and orientated x4, heart and lung sounds clear. Client urinating 100 mL/hour.

Client is tolerating soft diet and oral fluids. Bowel sounds are hyperactive in all 4 quadrants.

Bilateral pedal pulses 2+, Blood glucose 310 mg/dl. (74 to 106 mg/dL) 1400:

Temperature 36.8° C (98.2° F)

Pulse rate 84/min Respiratory rate 16/min

Blood pressure 106/76 mm Hg Oxygen saturation 96% on room air

A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take?

A nurse is planning care for a client who has developed nephrotic syndrome. Which of the following dietary recommendations should the nurse include?

A nurse is caring for a client who requires protective isolation following a hematopoietic stem cell transplant. Which of the following interventions should the nurse implement to protect the client from infection?

A nurse is planning to withdraw medication from an ampule to prepare for an injection. Which of the following actions should the nurse plan to take?

A nurse is preparing to receive a client from surgery following a transverse colon resection with colostomy placement. The nurse should expect to assess the stoma at which of the following locations? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

A nurse is providing discharge teaching to a client who reports that they cannot afford their prescribed medication. Which of the following statements should the nurse make?

A nurse is admitting a client who reports tightness in their chest that radiates to left arm.

Click to highlight the findings below that would indicate that the client has a potential problem. To deselect a finding, click on the finding again.

Nurses' Notes

1000:

Client reports tightness in chest that radiates to left arm. States pain as 7 on a scale of 0 to 10. Started to feel nauseous after breakfast. Client states, "I had scrambled eggs and bacon like I do every morning." Client is diaphoretic and short of breath. Heart rate irregular and tachycardic. Alert and oriented to person, place, and time. Lungs clear to auscultation in all lobes. Bowel sounds are present in all 4 quadrants. +1 pedal pulses. Skin is cool to touch. Capillary refill less than 2 seconds.

A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft?

A nurse is caring for a client who has cervical cancer and is receiving brachytherapy.

Which of the following actions should the nurse take?

A nurse is admitting a middle adult client who has cirrhosis.
Findings upon admission:

The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?

For each finding, click to specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition.

Findings 24 hr Later: Unrelated to Diagnosis /Indication of Potential Worsening/Indication of Potential Improvement Condition