The emergency department (ED) triage nurse receives a report from emergency medical services (EMS) on an older adult client being brought to the ED via EMS. After receiving the report, the nurse reviews the client's electronic medical record (EMR) for history and the most recent medication list.

1635: Most recent entry from a visit to primary care provider 5 days ago. Vital signs were BP 164/90, HR 96, RR 20, T 96.7°F (35.9°C), and SpO2 96% on room air. Past Medical History (PMH) positive for osteoporosis, a history of ovarian cancer treated with a hysterectomy and chemotherapy 16 years ago, hypercholesterolemia, and hypertension being managed with diet and exercise. During this recent visit, the client was started on hydrochlorothiazide (HCTZ) 12.5 mg, 1 tablet PO every AM. No Known Drug Allergies (NKDA). Additional home medications include:

• Atorvastatin 20 mg PO, 1 tablet every PM
• Calcium 1000 mg, 1 tablet PO BID
• multi-vitamin, 1 capsule PO every AM

The nurse obtained the bloodwork, started the IV, and administered morphine IV push.

> Complete the following sentence:

The nurse's highest priority is planning care knowing that the client is at risk for seizures due to

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An infant client has a tracheostomy. The nurse prepares to suction the tracheostomy. Which most important principle does the nurse use to plan care?

The nurse is caring for a client with a diagnosis of a ruptured appendix who underwent an emergency exploratory laparotomy with appendectomy 48 hours ago.

The 55-year-old client was admitted through the Emergency Department (ED) with fever, chills, nausea, and diffuse abdominal pain. Computed tomography (CT) of the abdomen confirmed a ruptured appendix with widespread inflammation. The client is 6'1" (193.04 cm) tall and weighs 260 lbs (117.93 kg). The client is obese with a BMI of 31.6 kg/m2. The client underwent an immediate exploratory laparotomy with appendectomy. The wound was not closed and was packed with sterile gauze.

The client's past medical history includes gastric reflux disease (GERD), hypertension, and type 2 diabetes mellitus. The client has no known drug allergies (NKDA). Home medications include lisinopril 20 mg 1 tablet PO every day, omeprazole 40 mg 1 capsule PO every day, metformin ER (extended-release) 750 mg 1 tablet PO every day, and acetaminophen 325 mg 2 tablets PO every 4 hours PRN for pain.

The physician is notified of the change in the client's wound. The nurse receives orders to obtain blood cultures x 2 and a culture of the wound now. The nurse prepares to change the client’s abdominal dressing and obtain a wound culture.

Which steps are appropriate for this procedure? (Select all that apply.)

The nurse delegated vital signs for a group of patients to the unlicensed assistive personnel (UAP). Which client condition would prohibit having a rectal temperature taken by the UAP?

The nurse provides care for a client having an incisional biopsy of a skin lesion. Which teaching about the care of the site does the nurse provide to the client?

The nurse provides care for a client recovering from a motor vehicle crash. For which sign of fluid volume overload does the nurse measure the client's intake and output? (Select all that apply)

The nurse is caring for a client with a diagnosis of a ruptured appendix who underwent an emergency exploratory laparotomy with appendectomy 48 hours ago. The 55-year-old client was admitted through the Emergency Department (ED) with fever, chills, nausea, and diffuse abdominal pain. Computed tomography (CT) of the abdomen confirmed a ruptured appendix with widespread inflammation. The client is 6'4" (193.04 cm) tall and weighs 260 lbs (117.93 kg). The client is obese with a BMI of 31.6 kg/m2. The client underwent an immediate exploratory laparotomy with appendectomy. The wound was not closed and was packed with sterile gauze.

Past Medical History (PMH) includes gastric reflux disease (GERD), hypertension, and type 2 diabetes mellitus. The client has no known drug allergies (NKDA). Home medications include:

1. Lisinopril 20 mg, 1 tablet PO every day
2. Omeprazole 40 mg, 1 capsule PO every day
3. Metformin ER (extended-release) 750 mg, 1 tablet PO every day
4. Acetaminophen 325 mg, 2 tablets PO every 4 hours PRN

The nurse medicates the client for pain prepares to irrigate the wound and completes the dressing change. The nurse observes a gush of fluid and sees a small portion of the client's intestine protrude from the wound bed. What actions does the nurse take immediately?

A client diagnosed with a bilateral hearing impairment seeks medical attention for an acute health problem. Which approach does the nurse use to enhance communication with this client?

The emergency department (ED) triage nurse receives a report from emergency medical services (EMS) on an older adult client being brought to the ED via EMS. After receiving the report, the nurse reviews the client's electronic medical record (EMR) for history and the most recent medication list.

The client was transferred to ED Bed 5 via stretcher. The client’s spouse is at the bedside. The client states "I feel so much better now except my wrist. It's really hurting." Advised to assess and then check with ED physician about something for the pain. VS BP 112/68 HR 99 RR 20. T 98.4° F (36.9° C). SpO2 96% on room air. The client is alert and oriented (A&O x 4), pleasant, and cooperative. PERRLA, skin intact with no bruising except for dorsal left forearm and wrist which is ecchymotic and edematous. Radial pulses are strong and equal (+3). Fingers warm with capillary refill - 3 sec. Lungs clear Abdomen soft with bowel sounds x 4 quadrants. Pedal pulse + x 4 and no pedal edema.

The client is being prepped for an open reduction internal fixation of the left wrist on the morning of day 2.

> Which three findings indicate that the client’s hemodynamic status has improved?

In which situation is the nurse determined to be negligent?

The nurse provides care for a child with an abdominal wound. The wound edges are approximated. Which does the nurse include when rendering the prescribed wound care to this child? (Select all that apply)