The nurse is assisting with the care of a client.

Exhibits

The nurse is collecting data on the client. Which of the following findings require follow-up?

Select all that apply.

A nurse is reinforcing teaching about saturated fats with a client who is at risk for cardiovascular disease. Which of the following cooking fats should the nurse recommend the client use?

A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care?

A nurse is contributing to the plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

A nurse is assisting with the plan of care for a client who has aspiration pneumonia and hypoxia. Which of the following actions should the nurse plan to take?

A nurse is reinforcing teaching with the family of a client who has methicillin-resistant Staphylococcus aureus (MRSA) of a leg wound and is on contact precautions. Which of the following statements by a family member indicates an understanding of the teaching?

A nurse is caring for a client who has a tracheostomy tube. Upon data collection, the nurse observes the client is restless and hears crackles in the lungs. Which of the following interventions should the nurse take?

A nurse is assisting in the care of the client who is postoperative following a fasciotomy.

The nurse is reviewing the client's electronic medical record (EMR). Click to highlight the statements in the EMR that indicate the client's condition is improving since implementing interventions. To deselect a finding, click on the finding again

Nurses' Notes

Day 3, 2300:

Client is alert and oriented to person, place, and time. Bilateral breath sounds clear and present throughout. Right leg with splint in place. Incisional dressing dry and intact. Wound drain to negative-pressure vacuum, draining small amounts of serosanguinous fluid. Bilateral pedal pulses 3+. Feet warm with intact movement and sensation. Client reports pain as a 4 on a scale of 0 to 10.

Vital Signs

Day 3, 2300:

Temperature 37.8° C (100° F)

Blood pressure 120/58 mm Hg

Heart rate 98/min

Respiratory rate 20/min

Oxygen saturation 95% on room air

A nurse in an assisted living facility is collecting data from an older adult client who fell in their room and hit their head on the dresser. Which of the following findings is the nurse's priority?

A nurse is caring for a client who is 6 hr postoperative following a bowel resection. Which of the following findings is the priority for the nurse to report?

A nurse is preparing to administer enoxaparin 1.5 mg/kg subcutaneously to a client who weighs 175 lb. How many mg should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)