The nurse is performing a respiration assessment on her client. The nurse begins counting the respirations when the second hand on the clock is at 12. When the nurse looks at the chest of the client he is exhaling. The client then continues to inhale and exhale 9 times. When the second hand on the clock is just past 5 the patient begins to inhale. When the second hand reaches the 6 the client has not exhaled. What would the nurse record in the chart as this client’s respiratory rate?

The nursing process guides nurses in delivery of care and includes sequential steps. Which step does the registered nurse (RN) perform within the nursing process that is not part of the standard of practice for the licensed practical nurse (LPN)?

The nurse is performing a respiration assessment on her client. The nurse begins counting the respirations when the second hand on the clock is at 12. When the nurse looks at the chest of the client he is exhaling. The client then continues to inhale and exhale 9 times. When the second hand on the clock is just past 5 the patient begins to inhale. When the second hand reaches the 6 the client has not exhaled. What would the nurse record in the chart as this client’s respiratory rate?

A nurse is administering enoxaparin 40mg subcutaneous to a client for prevention of blood clots when the client suddenly moves causing the needle to exit the client’s tissue and stick the nurse’s finger. What is the nurse’s first priority action?

The nurse assists the client back to bed from the bedside commode. What is the most important action the nurse can take to assure client safety prior to leaving the room?

During a physical assessment a nurse inspects a patient’s abdomen. What assessment technique would the nurse perform next?

A nurse is assessing the level of consciousness of a patient who has sustained a head injury in a motor vehicle accident. The nurse notes that the patient appears drowsy but the nurse is able to wake the patient by gently shaking and calling the patient by name. What level of consciousness would the nurse document?

A nurse is repositioning a client who has physical limitations due to recent back surgery. How often would the nurse turn the client in bed?

The nurse on the progressive care unit is preparing to perform a sterile wet to dry dressing change on a client with a sacral pressure ulcer. The nurse notes that the sterile saline at the bedside is marked as opened 48 hours ago. What is the nurse’s priority action?

The nurse is taking a radial pulse and assessing the pulse amplitude for a patient. Documentation by the nurse states. “Pulses are +3 in the upper extremities.” What amplitude is the nurse assessing?

The nurse understands that sequential compression devices and compression stockings are used for which of the following?