In determining the one minute Apgar score of a neonate, the nurse assesses a heart rate of 120 beats per minute and 44 respirations per minute. The neonate has flaccid muscle tone with slight flexion and slight resistance to straightening, a loud cry with stimulation, and acrocyanotic color. Which is the correct Apgar score for this neonate?

The post anesthesia care unit (PACU) nurse uses the SBAR format in reporting to the surgical unit nurse regarding an older client who had a right total hip replacement for avascular necrosis. Vital signs are reported, which are all stable and within normal limits. The nurse also reports that the client was medicated for pain with morphine 2 mg IV and ondansetron 4 mg IV 45 minutes ago, which reduced the pain level to 4 on a 0 to 10 scale, but the client is still nauseated. Which additional information is critical for the PACU nurse to include in the SBAR format report? Select all that apply.

A 6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy. Which pre-operative nursing action has highest priority?

The charge nurse in an extended care facility is organizing unit activities for the day. Which action may be safely delegated to the practical nurse (PN)?

Patient Data  

For each action, identify if it is indicated or not indicated when monitoring the effects of lorazepam administration. Each row must have one response action selected.

The nurse is reviewing a pregnant client's prenatal immunization history. Which immunization should the nurse instruct the client to receive after pregnancy?

Patient Data

The nurse performs an initial rapid assessment of the client and observes facial drooping and garbled speech.

Drag one condition and one client finding to complete the sentence(s). Based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of

A group of nurses implement a pilot study to evaluate a proposed evidence-based change to providing client care. Evaluation indicates successful outcomes and the nurses want to integrate the change throughout the facility. Which actions should be taken? Select all that apply.

Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain?

An older adult client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). The client has facial paralysis and cannot move the left side of the body. When entering the room, the nurse finds the client's spouse tearful and trying unsuccessfully to give the client a drink of water. Which action should the nurse take?

A client is receiving IV fluids by gravity infusion and exhibits signs of fluid volume overload. When assessing the client's IV delivery system, where should the nurse assess first?