A nurse is caring for a client who is restrained to each extremity. Which of the following assessments should the nurse perform first?

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.

When reviewing the medical record of a client who asks about the use of magnet therapy for pain relief, which of the following findings is a contraindication for receiving this type of therapy?

A nurse is teaching a client who is about to undergo a bowel resection about advance directives.

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?

A nurse is caring for a client who is restrained to each extremity. Which of the following assessments should the nurse perform first?

A nurse is providing teaching for a client who is scheduled for an allogeneic stem cell transplant.

Which of the following information should the nurse include?

A charge nurse in a long-term care facility is preparing an educational program about delirium for newly hired nurses. Which of the following statements should the nurse plan to include?

A nurse is planning care for a client who is concerned about her tobacco smoking habits and is in the contemplation stage of health behavior change.

Which of the following actions should the nurse plan to take during this stage?

A nurse is caring for a client.

What are the first two actions the nurse should take?

A nurse is delegating client care tasks to assistive personnel.

Which of the following tasks should the nurse delegate?