A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8° C (98.2° F). Which of the following actions should the nurse perform?

A home health nurse is conducting a home safety assessment for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? (Select all that apply.)

An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure?

A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take?

A nurse is caring for a client.

Nurses' Notes

Day 1:

1300:

Client has a 2.5 cm (1 in) x 2.5 cm (1 in) stage 2 pressure injury to dorsal lateral aspect of left heal; wound bed red, moist, approximated edges; surrounding skin inflamed, red,, non-tender to palpation. Client reports pain score of 0 on 0 to 10 pain scale. Pedal pulse left foot 1+, unable to assess capillary refill due to toe fungus bilaterally, Pedal pulse right foot 2+. Wound care as prescribed; heel floated on pillow.

Medical History

Day 1:

Diabetes mellitus Hyperlipidemia

Labs

Day 1

Hct 38% (37% to 47%)

Hgb 13 (12 g/dL to 16 g/dL)

WBC 11,500/mm3 (5000 to 10,000/mm3)

Potassium 3.6 mEq/L (3.5 mEq/L to 5 mEq/L)

Pre-albumin level 10 mg/dL (15 to 36 mg/dL)

Albumin: 3.0 g/dL (3.5 to 5 g/dL)

Fingerstick blood glucose, fasting 186 mg/dL (74 to 106 mg/dL)

Select the 5 findings that can cause delayed wound healing.

A nurse is caring for several clients who are at various developmental stages. The nurse should explain that, according to Erikson, acceptance of death is a primary task of which of the following stages of psychosocial development?

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take?

A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to assistive personnel (AP)? (Select all that apply.)

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

A nurse is having difficulty caring for a client due to variables affecting the communication process. Which of the following should the nurse identify as an interpersonal variable? (Select all that apply.)

A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations?