A nurse is preparing to administer an injection to a client. Which of the following actions should the nurse plan to take after administering the Injection?

A nurse is caring for a client who is scheduled to have his alanine aminotransferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse?

A nurse is caring for a client.

Click on the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Nurses' Notes

1500:

Client is alert and oriented to person, place, and time. Client is 4 hr postoperative following abdominal surgery. Surgical site has a small amount of serosanguineous drainage on dressing. Dressing is intact. Client reports pain as 5 on a scale of 0 to 10. Lung sounds are diminished in posterior lobes. Bowel sounds are hypoactive in all 4 quadrants. Last bowel movement was this morning.

1730:

Client is restless and short of breath. Reports pain as 8 on a scale of 0 to 10. Pain medication administered.

Vital Signs

1730:

• Temperature 37.2° C (98.9° F)
• Blood pressure 168/84 mm Hg
• Heart rate 116/min
• Respiratory rate 24/min
• Oxygen saturation 93% on room air

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 preparing to perform a physical assessment of a client's abdomen. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A nurse is delegating client care tasks to assistive personnel. Which of the following tasks should the nurse delegate?

A nurse is preparing to administer a controlled substance to a client for pain management. Which of the following actions should the nurse take?

A nurse is caring for a client who refuses to follow the provider's prescription for strict bed rest. The nurse overhears an assistive personnel (AP) telling the client, "If you do not remain in bed, I will place you in restraints." The nurse should identify that the AP is committing which of the following torts?

A nurse in a health clinic is caring for a client.

Click to highlight the findings that the nurse should report to the provider. To deselect a finding, click on the finding again.

Nurse's Notes and Diagnostic Results

Vital Signs 0930:

• Temperature: 39.3° C (102.8° F)
• Heart rate: 113/min
• Respiratory rate: 24/min
• Blood pressure: 122/68 mm Hg
• Oxygen saturation: 96% on room air

Nurses' Notes 0930:

• Client reports 2-day history of urinary frequency, burning on urination, and lower back and suprapubic pain. States developed a fever this morning.
• Oriented x 4, answers questions appropriately.
• S1, S2 on auscultation. Lungs clear on auscultation.
• Bowel sounds x 4 quadrants active, denies nausea or vomiting.

Diagnostic Results 1030:

• Urinalysis:
  • Appearance: cloudy (clear)
  • Colour: cloudy (amber yellow)
  • Odour: foul (aromatic)
  • pH: 8.0 (4.6 to 8.0)
  • Protein: 6.5 mg/dL (0 to 8 mg/dL)
  • Specific gravity: 1.035 (1.005 to 1.030)
  • Leukocyte esterase: positive
  • Nitrites: present
  • Ketones: none (none)
  • Bilirubin: none (none)
  • Crystals: none (none)
  • Casts: none (none)
  • Glucose: none (none)
  • White blood cells: 8 (0 to 4)
  • Red blood cells: 3 (less than 2)

A nurse is providing teaching to a client who has a newly prescribed hearing aid. Which of the following statements by the client indicates an understanding of the teaching?

A nurse in a health clinic is caring for a client. Click to highlight the findings that the nurse should report to the provider. To deselect a finding, click on the finding again.

Nurse's Notes

0930:

• Client reports 2-day history of urinary frequency, burning on urination, and lower back and suprapubic pain. States developed a fever of 39.3°C (102.8°F) this morning.
• Oriented x-4, answers questions appropriately.
• S1, S2, on auscultation. Lungs clear on auscultation.
• Bowel sounds x 4 quadrants active, denies nausea or vomiting.

0945:

• Request client provide clean-catch urinary specimen for testing.
• Urinalysis results reviewed.

Vital Signs 0930:

• Temperature: 39.3°C (102.8°F)
• Heart rate: 113/min
• Respiratory rate: 24/min
• Blood pressure: 122/68 mm Hg
• Oxygen saturation: 96% on room air

Diagnostic Results 1030:

Urinalysis

• Appearance: Cloudy
• Color: Amber yellow
• Odor: Aromatic
• pH: 8.0 (Reference: 4.6 to 8.0)
• Protein: 6.5 mg/dL (Reference: 0 to 8 mg/dL)
• Specific gravity: 1.035 (Reference: 1.005 to 1.030)
• Leukocyte esterase: Positive
• Nitrites: Present
• Ketones: None
• Bilirubin: None