Patient Data

A history is completed by the healthcare provider (HCP) with a rapid assessment, and vital signs completed by the nurse

 Click to highlight the findings that require follow up.

• Neurological: Alert and oriented person, place, time, and situation. Agitated. Denies headaches.
• Cardiovascular: Reported chest pain described as pressure and tightness that is unrelieved with rest. Rapid regular rhythm. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.
• Respiratory: Rapid and shallow breaths. Clear breath sounds throughout bilateral lungs.
• Gastrointestinal: Within normal limits (WNL).
• Genitourinary: WNL
• Musculoskeletal: WNL
• Pain: Reported 7 on a 0 to 10 scale, tightness and pressure in chest. Started approximately 2 hours ago and got progressively worse, unrelieved by rest.

Patient Data

A history is completed by the healthcare provider (HCP) with a rapid assessment, and vital signs completed by the nurse

 Click to highlight the findings that require follow up.

• Neurological: Alert and oriented person, place, time, and situation. Agitated. Denies headaches.
• Cardiovascular: Reported chest pain described as pressure and tightness that is unrelieved with rest. Rapid regular rhythm. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.
• Respiratory: Rapid and shallow breaths. Clear breath sounds throughout bilateral lungs.
• Gastrointestinal: Within normal limits (WNL).
• Genitourinary: WNL
• Musculoskeletal: WNL
• Pain: Reported 7 on a 0 to 10 scale, tightness and pressure in chest. Started approximately 2 hours ago and got progressively worse, unrelieved by rest.

The nurse is caring for a client with the sexually transmitted infection (STI) human papillomavirus (HPV). The client reports having had prior sexually transmitted infections. Which response should the nurse provide?

The nurse is performing an initial wound assessment on a client's pressure injury and notes severe tissue destruction inhibiting the wound edges to approximate. Which wound healing technique will likely be used?

The nurse is conducting a visual screening of a group of older adults. Which finding should the nurse report to the healthcare provider immediately?

Which characteristic of a hypertensive crisis should the nurse recognize?

Patient Data

For each nursing action, click to indicate whether the action is a therapeutic communication or a nontherapeutic communication. Each row must have only one response option selected.

The nurse is caring for a client who reports sudden right-sided numbness and weakness of the arm and leg. The nurse also observes a distinct right-sided facial droop. After reporting the findings to the healthcare provider (HCP), the nurse receives several prescriptions for the client, including a STAT computerized tomography (CT) scan of the head. Which intervention should the nurse perform in the immediate management of the client?

While the nurse is conducting an admission assessment of a female client with bipolar disorder, the client suddenly begins to take off her clothes and throw them about the room. Which action should the nurse take first?

Patient Data

The nurse is evaluating the interventions completed by the team during the delivery.

Click to highlight the findings that would indicate that the client and/or newborn are not stable at this time.

Vacuum-assisted vaginal delivery of a viable male infant over a second- degree perineal laceration repaired under local anesthesia. There is maternal quantitative blood loss of 1,100 mL.

The newborn is attended by the neonatal team. Apgar scores are 3/4/7.

The newborn's oxygen saturation is 84%. Caput succedaneum and acrocyanosis are noted.

The charge nurse in a critical care unit is reviewing client conditions to determine who is stable enough to be transferred. Which client status report indicates readiness for transfer from the critical care unit to a medical unit?

Reference Range:

Hemoglobin (Hgb) [14 to 18 g/dL (140 to 180 g/L)]