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 preparing to replace a client's transdermal fentanyl patch after 72 hr of use. After the nurse opens the packet containing the new pouch, the client declines to accept it. Which of the following actions should the nurse take?

A nurse is caring for a client who is 1 day postoperative following a total thyroidectomy.

Complete the following sentence by using the lists of options.

The client is at highest risk for developing

A nurse is providing education to the parent of a school-age child who has asthma. Which of the following statements by the parent indicates an understanding of the teaching?

A nurse is caring for a client who is 1 hr postpartum.

Nurses' Notes

1200:

Large amount of lochia rubra noted on perineal pad. Fundus boggy at two fingerbreadths above the umbilicus. Oxytocin 20 units being administered via continuous JV infusion.

1215:

Large amount of lochia rubra with several large clots noted. Client reports feeling anxious. Skin cool and clammy. Provider notified.

Select the 6 actions the nurse should take.

A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take?

A nurse is teaching a client who has a new prescription for total parenteral nutrition through a central line. Which of the following information should the nurse include in the teaching?

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?

A nurse is caring for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Before administering an antibiotic that can cause nephrotoxicity, which laboratory value is most important for the practical nurse (PN) to review?

A nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following interventions should the nurse include in the plan?