A nurse is caring for a client who is taking disulfiram for alcohol use disorder and reports ingestion of alcohol.
For which of the following adverse effects should the nurse monitor?

A nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis. Which of the following actions should the nurse include in the plan of care?

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

Vital Signs Day 1,

0900:

Admission:

Temperature 38.4° C (101.1° F) Heart rate 92/min Respiratory rate 18/min Blood pressure 130/78 mm Hg
Pre-pregnancy BMI 27.6 Current BMI 29.9

The client is at risk for developing which of the following 2 complications? Select 2 complications the client is at risk of developing.

The nurse is caring for a client who reports sudden right-sided numbness and weakness of the arm and leg. The nurse also observes a distinct right-sided facial droop. After reporting the findings to the healthcare provider, the nurse receives several prescriptions for the client, including a STAT computerized tomography scan of the head.

After obtaining vital signs, the nurse should implement which intervention?

A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis following a stroke. Which of the following actions by the nurse best promotes communication among staff caring for the client?

Select the 4 findings that require follow-up.

A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?

While performing a routine assessment, a nurse notices fraying on the electrical cord of a client's continuous passive motion (CPM) device. Which of the following actions should the nurse take first?

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.