A nurse is teaching a home care client and the family about using prescribed oxygen. What is a critical factor in regard to safety that must be included in teaching?

The nurse is inserting an indwelling urinary catheter for a male client. As the catheter is inserted into the
urethra, urine begins to flow into the tubing. When should the nurse inflate the balloon?

A nurse notes that a client is confused, impulsive, and unstable with mobility. The nurse fears the client is in danger of harming themselves so they ask for a sitter to stay at the bedside to keep the client company and minimize the risk for falls. What ethical principle is the nurse demonstrating?

A nurse is managing a patient's fluids and outputs over a shift. Here are the details:

• 0700: The nurse starts an IV of 0.45% Normal saline infusing at 100 mL/hr.
• 0900: The patient has coffee-ground emesis (vomit) measuring 300 mL.
• 1000: The nurse stops the IV of 0.45% Normal saline to administer an IV antibiotic. The antibiotic administered is Kefzol 1 g in 25 mL of D5W over 30 minutes.
• 1030: The antibiotic infusion stops, and the nurse resumes the IV fluid of 0.45% Normal saline at 100 mL/hr.
• 1100: The physician orders the insertion of an NG tube and intermittent suction. The nurse inserts the NG tube and connects it to intermittent suction.
• 1530: The patient voids another 350 mL and 200 mL. The nurse checks the NG tube canister and records the output for the shift as 300 mL.

Calculate the patient's total intake from 0700 to 1530.

A graduate nurse enters a client's room and finds the client unresponsive, not breathing, and without a carotid pulse. The graduate nurse is aware that the client has mentioned that he does not wish to be resuscitated, but there is no DNR order on the client's chart. What is the nurse's best action?

The nurse is caring for a patient who is confused and agitated. The patient continues to get out of bed without assistance and is at high risk for falls. The nurse is considering alternatives to implement prior to applying restraints.

Of the following, which would the nurse NOT consider in the plan of care as an alternative to restraints?

The nurse is planning to care for a client with an indwelling catheter. Which of the following measures should the nurse implement when performing hygiene care in regards to the indwelling catheter?

The nurse is performing a head-to-toe assessment on a patient. The nurse uses their thumb and first finger to lift or pinch a fold of skin under the clavicle to check for skin turgor. Which of the following findings would be considered normal for this assessment?

A nurse is caring for a client who has a history of falling at their assisted living facility. The client is oriented
to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall?

Which of the following is the best example of a measurable client goal? The clientwill:

A new nurse understands that documentation guidelines are important to ensure accuracy. The nurse would perform which of the following documentation guidelines? Select all that apply.