A nurse is teaching a prenatal class about infection prevention at a community centre. Which of the following statements by a client indicates an understanding of the teaching?

A nurse is caring for a client who is postoperative following an appendectomy.

Vital Signs

1800:

Temperature 98.4° F (36.8° C) Heart rate 104/min

Respiratory rate 22/min

Blood pressure 142/80 mm Hg

O2 saturation 97% on room air

1800:

Client alert and oriented x 4

Skin warm and dry

Lungs clear on auscultation

Bowel sounds hypoactive in all four quadrants Urine clear yellow

Incisional dressing clean and dry

Client reports pain as 6 on a scale of 0 to 10

1815:

Morphine administered as prescribed

2000:

Temperature 98.4° F (36.8° C) Heart rate 110/min Respiratory rate 24/min

Blood pressure 158/88 mm Hg O2 saturation 93% on room air

Which of the following 4 client findings should the nurse report to the provider?

A nurse is caring for a client who is in labour and notes that the umbilical cord is prolapsed. Which of the following actions should the nurse take?

A nurse manager in a long-term care facility is having difficulty with staffing for weekend shifts and is planning to implement some changes to the scheduling procedure. Which of the following actions should the nurse manager take first?

The practical nurse (PN) is told that she keeps her 2-year-old child in a playpen so he will not get dirty. Which statement should the PN use in responding to this concern about using a playpen?

A nurse is caring for a client receiving mechanical ventilation via an endotracheal (ET) tube. The high-pressure alarm is beeping, and the client is experiencing respiratory distress. The nurse is unable to determine the cause of the alarm. Which of the following actions should the nurse take?

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 nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia?

A nurse is preparing to administer levothyroxine 50 micrograms to a client. Available is levothyroxine 0.025 mg/tablet. How many tablets should the nurse administer per dose?

(Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. Upon arrival at the playground, which of the following actions should the nurse take first?

A nurse is caring for a client who is pregnant.

Exhibit 1

Nurses' Notes

1000:

The client reports repeated episodes of vomiting and two episodes of diarrhea in past 24 hr. Client is at 18 weeks of gestation and reports a history of nausea and vomiting for the past 12 weeks.

1015:

IV fluids initiated. Prochlorperazine administered via intermittent IV bolus.

1100:

Client reports improvement in nausea. Ice chips provided. Client voided 50 mL of dark yellow urine.

1500:

Client tolerating fluids well. Ate four graham crackers without emesis. Has voided 300 mL of amber-colored urine.

Exhibit 2

Vital Signs

1000:

Temperature 36.8° C(98.2° F)

Heart rate 112/min

Respiratory rate 20/min

Blood pressure 100/65 mm Hg

SaO 97% on room air

1200:

Temperature 37° C(98.6° F)

Heart rate 102/min

Respiratory rate 20/min

Blood pressure 104/70 mm Hg

SaO2 98% on room air

1500:

Temperature 36.8° C(98.2° F)

Heart rate 90/min

Respiratory rate 18/min

Blood pressure 110/72 mm Hg

SaO2 97% on room air

For each discharge instruction, specify if each action is recommended or contraindicated for the client.