Exhibits

Click to indicate which client goal is being met by each of the client data. Each column must have at least one response selected.

Following a bowel resection, a client's tympanic temperature was 97.6° F (36.4° C) on admission to the postanesthesia care unit (PACU). Thirty minutes later, the temperature is 101.6°F (38.7° C). Which intervention(s) should the nurse implement? Select all that apply.

A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instruction(s) should the nurse give to the unlicensed assistive personnel (UAP) who is assisting with the client's care? Select all that apply.

Patient Data

Review H and P, nurse's notes, laboratory results, flow sheet, and prescriptions. Select the 3 findings that would require immediate action from the nurse while the laboring mother is receiving an epidural anesthesia.

A 2-month-old infant with hypertrophic pyloric stenosis is receiving parenteral fluids for rehydration and decompression of the stomach while waiting for surgical repair. To maintain normal growth and development of the child during this period, which action should the nurse include in the plan of care?

The nurse is stabilizing the client and preparing her for surgery.

What goal(s) should the nurse prioritize in the care plan for the client while in the emergency department? Select all that apply.

The nurse is managing the care for a client with hyperparathyroidism, and is reviewing the client's list of prescribed and over-the-counter medications. Which medication(s) on the client's current medication record should the nurse discuss further with the healthcare provider? Select all that apply.

The nurse is developing a plan of care for an older male client with type 2 diabetes who reports blurred vision. Which outcome should the nurse include in the plan of care for this client?

The nurse suspects elder mistreatment.

Click to indicate if the listed manifestation of abuse is consistent with physical abuse, abandonment, or neglect. Each row must have only one response option selected.

A client who received an open reduction and internal fixation (ORIF) of the right femur after experiencing a fall at home experiences a sudden onset of increasing confusion and agitation. When reporting to the healthcare provider using SBAR (Situation. Background, Assessment, Recommendation) communication, which information should the nurse provide first?

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?