A nurse is considering placing wrist restraints on a client who has cognitive deficits and has pulled out their IV catheter. Before using wrist restraints, which of the following actions must the nurse take first?

A nurse is observing a newly licensed nurse care for a client who is at increased risk for infection. Which of the following actions indicate the newly licensed nurse is following recommended medical asepsis practices?

A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?

A nurse is assessing a client whose therapy has included bed rest for several weeks.
Which of the following findings should the nurse identify as the priority?

A home health nurse is caring for a group of older adult clients. Which of the following statements by a client is an indication they may be experiencing social isolation?

A nurse is caring for a client who was recently diagnosed with a terminal illness. The client tells the nurse, "I am looking forward to seeing my grandchildren grow up." The nurse should identify that the client is experiencing which of the following stages of grief?

A nurse on a surgical unit is caring for a client who is scheduled for surgery. The client states. "I cannot do this. I do not want this surgery." Which of the following actions should the nurse take?

A nurse is teaching a client who can only bear weight on one leg how to ambulate using crutches. Which of the following crutch gaits should the nurse plan to instruct the client to use?

A nurse is caring for a client who is scheduled for an appendectomy.

Exhibit 1 Exhibit 2 Exhibit 3

Nurses' Notes

1050:

Received handoff report from the ED nurse for a client who has acute appendicitis and is scheduled for an appendectomy. Client reports that pain began in the midabdominal region during the night. This morning the pain intensified and localized to the right lower quadrant region. Pain continues to intensify. rebound tenderness noted. Reports vomiting one time after eating a piece of toast at 0600 with continued feelings of nausea.

Peripheral IV to the left forearm with IV fluids infusing.

1200:

Informed consent obtained by the surgeon performing the procedure. Placed in the client's medical record. Client expressing concern about potential complications that could result from the surgery.

Medical History

1050:

Received influenza vaccine 1 month ago.

Thyroid disease, taking levothyroxine for 14 years. History of cholecystectomy 3 years ago.

Denies alcohol or illegal drug use. Reports smoking approximately 6 cigarettes per day for the past 10 years. Allergic to shellfish, latex, and penicillin.

Vital Signs

0945, Upon admission to emergency department (ED): Temperature 38.3°C(100.9° F)

Pulse rate 102/min Respiratory rate 22/min

Blood pressure 122/80 mm Hg Oxygen saturation 96% on room air Pain reported as 6 on a scale of 0 to 10.

1050, Upon admission to medical-surgical department Temperature 38,4° C (101.2° F)

Pulse rate 104/min Respiratory rate 22/min

Blood pressure 124/80 mm Hg Oxygen saturation 96% on room air Pain reported as 8 on a scale of 0 to 10

The nurse is preparing the client for surgery. Select the 4 findings that require follow-up prior to surgery.

A charge nurse is teaching a group of nurses about decreasing the risk for catheter- associated urinary tract infections in clients. Which of the following information should the nurse include in the teaching?

A staff nurse is teaching a newly hired nurse how to complete an informed consent document for a client. The staff nurse should include that the nurse's signature on the form confirms which of the following requirements? (Select all that apply)