A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina.

Which of the following statements by the client indicates an understanding of the teaching?

A nurse is assisting with food selection for a client who follows kosher dietary traditions.

Which of the following food choices should the nurse include on the client’s food tray?

A home health nurse is caring for a child who has Lyme disease.

Which of the following is an appropriate action for the nurse to take?

A nurse is caring for a school-age child who is postoperative and received morphine via IV bolus for pain 10 min ago.

Which of the following findings is the nurse’s priority?

A nurse is preparing to administer vancomycin IV to an adult client.

The client asks the nurse if the medication can be given 2 hr earlier.

Which of the following statements should the nurse make?

A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina.

Which of the following statements by the client indicates an understanding of the teaching?

nurse is caring for an adult client who has chronic anaemia and is scheduled to receive a transfusion of 1 unit of packed RBCs. Which of the following actions should the nurse take?

A nurse is assessing a client who is in active labor.

Which of the following findings should the nurse report to the provider?

A nurse in an emergency department is assessing an adolescent who has conduct disorder.

Which of the following questions is the priority for the nurse to ask the client?

A nurse is caring for a 2-month-old infant who has heart failure.

Which of the following actions should the nurse take?

A nurse in an emergency department is caring for a client. Nurses' Notes.

1200:.

Client is an 82-year-old male who presents with his adult child for evaluation of right arm pain after a fall. Client noted to have several superficial abrasions on right forearm and elbow. Also has numerous bruises in various stages of healing on arms and upper chest. Client rates pain in right lower forearm an 8 on a 0 to 10 pain scale and is not moving the arm.

1210:.

Client noted to keep head down and makes limited eye contact. Speaks very softly and looks at adult child before answering interview questions. Has strong body odor and clothes are unclean. Client's adult child answers most questions. Client grimacing and guarding right arm.

Client weighed, is 56.2 kg (124 lb) and 175 cm (69 in) tall. BMI 18.3.

1230:.

Client's adult child left facility to go home and get the client’s prescribed medications. Client visibly more relaxed and now speaking more openly to staff with improved eye contact. Client reports that he has lived with his adult child for the past several.

Vital Signs. 1200:.

Temperature 36.7° C (98° F). Heart rate 96/min.

Blood pressure 142/96 mm Hg. Respiratory rate 16/min.

SpO2 97% on room air.

The nurse is preparing to speak to the facility's Social Worker about the client's condition.

Select the 5 findings the nurse should plan to include in the report.