A nurse is contributing to the plan of care for a client who is experiencing a herpes simplex outbreak. Which of the following interventions should the nurse recommend?

A nurse is collecting data from a toddler during a well-child visit. Which of the following actions should the nurse take to prepare the toddler for a physical examination?

A nurse is caring for a client who is to begin chemotherapy. The client asks the nurse about managing hair loss. Which of the following responses should the nurse make?

A nurse is assisting in providing postmortem care for a client who was a devout follower of Hinduism. Which of the following requests should the nurse anticipate from the client's family?

The nurse is reviewing the medical records of the client who is exhibiting mania. Which of the following actions should the nurse take? Select all that apply.

Vital Signs 0800:

Heart rate 110/min Respiratory rate 20/min

Blood pressure 132/80 mm Hg Temperature 37.2° C (99° F)

1100:

Heart rate 120/min

Respiratory rate 24/min

Blood pressure 149/90 mm Hg Temperature 37.2° C (98.9° F)

The nurse is preparing the client for discharge. Provider Prescriptions:

Ethambutol 1,200 mg PO daily Rifampin 600 mg PO daily Isoniazid 300 mg PO daily Pyrazinamide 1,600 mg PO daily

Acetaminophen 650 mg PO three times daily every 6 hr PRN for fever greater than 38°C (100.4°F).

Discharge prescriptions, 0800:

Ethambutol 1,200 mg PO daily Rifampin 600 mg PO daily Isoniazid 300 mg PO daily Pyrazinamide 1,600 mg PO daily

Which of the following statements indicates the client understands the discharge teaching?

Select the 3 client statements that indicate an understanding of the teaching.

Nurses' Notes Postoperative Day 3 0900:

The client reports pain at the surgical incision site as 5 on a scale of 0 to 10. The client reports bladder fullness. Perineal dressing intact with minimal serosanguinous drainage. The client transferred out of bed to a chair independently. Extremities cool and dry with 2+ peripheral pulses.

1300:

The client reports abdominal cramping and small, hard, painful bowel movements after lunch. Ambulating independently in the hallway. Reports pain as 8 on a scale of 0 to 10. Urinary catheter intact with 100 mL/hr. of pink urine.

Select the 2 actions the nurse should prepare to take for the client.

The nurse is reviewing the client's medical record.

Procedures

Planned endoscopy at 1300.

The nurse is assisting with the care of the client prior to a blood transfusion. Which of the following actions should the nurse take?

Select all that apply.

A community health nurse is assisting with the development of a pamphlet regarding choking hazards for toddlers. Which of the following foods should the nurse include?

A charge nurse is reinforcing teaching with a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Nurses' Notes Preoperative 0730:

The client is scheduled for a left stapedectomy.

Pupils 3.5 mm, equal, round, and reactive to light. Smile symmetrical.

Mucous membranes show color expected for the client's skin tone and moisture.

Speech clear.

Skin warm and dry. Lungs clear bilaterally.

Apical heart rate regular at 78/min. Postoperative

1230:

Pupils were 3 mm, equal, and reactive to light.

Smile asymmetrical. Mucous membranes pink. Speech hoarse.

Client with left facial droop Skin warm and dry.

The client reports vertigo and nausea.

Bilateral breath sounds clear and present throughout. Apical heart rate regular at 92/min.

The client reports left ear discomfort and rates the pain as 5 on a scale of 0 to 10. The client states that her hearing has diminished following surgery.

Which of the following findings requires further action by the nurse? Select all that apply.