A nurse is caring for a client who has a spinal cord injury.

Nurses' Notes 0600:

Adventitious lung sounds auscultated in lower lobes bilaterally. Spirometry encouraged. Cough productive for clear sputum.

1000:

Cough productive for clear sputum following incentive spirometry and coughing exercises. Face and neck flushed. Client reports headache.

Abdomen distended. Last bowel movement was 2 days ago with hard stool. Provider Prescriptions

Nifedipine 30 mg PO for blood pressure greater than 150/100 mm Hg and notify provider Acetaminophen 650 mg PO q4 hr PRN pain

For each potential nursing action, click to specify if the action is anticipated or contraindicated for the client.

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?

A nurse is planning to teach a client about taking prednisone. Which of the following instructions should the nurse include?

A nurse is reviewing the medical records of four clients. The nurse should identify which of the following client findings that requires follow-up care.

A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following actions should the nurse plan to take?

A nurse is teaching a prenatal class about infection prevention at a community center.
Which of the following statements by a client indicates an understanding of the teaching?

A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan?

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

The nurse reviews the entries in the medical record.

Admission Assessment 0900:
Client reports, "I'm bloated and my stomach hurts." History of prior illness: Client reports a 3-week history of gnawing abdominal pain. Client states, "It's a burning sensation that radiates to my back. I think I've lost a little weight too." Reports one episode of dark, tarry stool. No vomiting. Client reports pain is worse about 1 hr after eating a meal. Past medical history: Osteoarthritis
Social history: Recently divorced, drinks in moderation (3 to 4 drinks per week), smokes tobacco
Current medications:

Ibuprofen 800 mg three times daily PRN arthritis pain Physical Examination:

General: client appears uncomfortable, diaphoretic

Head, ears, eyes, nose, and throat (HEENT): oropharynx clear, mucous membranes moist and pale
Respiratory: bilateral breath sounds clear

Gastrointestinal: epigastric tenderness to palpation, no rebound tenderness or guarding Neurological: oriented x 3 (person, place, and time)

The nurse is ready to begin. For each potential nursing action, specify if the action is indicated or not indicated for the client.
Nursing Actions

A nurse is teaching a class about providing care within the legal scope of practice to a group of nurses.
The nurse should include that which of the following procedures is outside the legal scope of practice for an RN?