A nurse is preparing to replace a client's transdermal fentanyl patch after 72 hr of use. After the nurse opens the packet containing the new pouch, the client declines to accept it. Which of the following actions should the nurse take?

A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory tests should the nurse review prior to adjusting the client's heparin?

A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?

In caring for a client who requires seizure precautions, the practical nurse (PN) should ensure the ready availability of equipment to perform which procedure?

A nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following activities is the nurse's priority?

A nurse is performing a skin assessment on a client who has a dark skin. Which one of the following locations on the client’s body should the nurse observe to access for jaundice?

A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider?

The nurse is assessing the adolescent 4 hr following fasciotomy. Highlight the findings below that indicate the adolescent's condition is improving.

Admission Assessment

1400:

Adolescent brought to emergency department by parents following a fall while skateboarding. Adolescent reports pain in their right leg as 10 on a scale of 0 to 10 and is unable to bear weight.

Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with active bowel sounds in all four quadrants. Right lower extremity with open wound and displaced bone. Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds.

Nurses' Notes 2300:

Adolescent is drowsy and reports nausea. Respirations shallow. Lungs clear. Unproductive cough present. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with hypoactive bowel sounds in all four quadrants. Right lower extremity fasciotomy, dressing clean, dry, and intact. Extremity pulse +3. Capillary refill 2 seconds. Right extremity is warm to the touch. Adolescent reports no numbness or tingling. Adolescent reports pain as 2 on a scale of 0 to 10.

A charge nurse is speaking with the partner of a client. The partner states that the client is not receiving adequate care. Which of the following actions should the charge nurse take first to resolve the situation?

A nurse is caring for an adolescent.
Admission Assessment
1400:

• Adolescent brought to emergency department by parents following a fall while skateboarding.
• Adolescent reports pain in their right leg as 10 on a scale of 0 to 10 and is unable to bear weight.
• Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm.
• Abdomen soft and nontender with active bowel sounds in all four quadrants.
• Right lower extremity with open wound and displaced bone.
• Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds.

Select the 4 findings that require follow-up.

A nurse is assessing a client who has major depressive disorder and is taking amitriptyline. Which of the following findings should the nurse identify as an adverse effect of the medication?