The nurse omits to document an assessment finding that resulted in a significant client injury. For which legal issue does the nurse need to prepare?

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.

15:45: Client transferred to ED Bed 5 via stretcher by EMS. The client's spouse is at the bedside. Client states "I feel so much better now, except for my wrist is really hurting." Advised will assess then check with the 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 strong and equal (+3), fingers warm with capillary refill < 3 sec. Lungs are clear, abdomen soft with bowel sounds x 4 quadrants, pedal pulses (+) x 4, and no pedal edema.

The nurse assesses the client and reviews the orders from the ED physician, gathers supplies to draw the lab work, starts the IV, and administers the morphine IVP.

Select the supplies the nurse gathers (Select all that apply.)

A client recovering from surgery sits in a chair for breakfast. Which action does the nurse take before applying newly prescribed anti-embolism stockings to the client's lower extremities?

While the nurse prepares an injection for a client, the needle cap falls on the floor. Which action indicates that the injection will be sterile?

A family member tells the nurse, "I overheard a caregiver threaten my uncle." The family member said the caregiver remarked, "If you don't learn to calm down, I will have to restrain you." Based on this information, which criminal offense does the nurse communicate to the nurse manager?

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 receives a diagnosis of right-sided paralysis. Which action does the nurse take when assisting the client in transferring from the bed to the wheelchair?

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?

The nurse plans care for a client who reports avoiding people because of having scabies and difficulty walking. Which statement does the nurse document as the client's greatest concern?

The nurse provides care for a client with a poor appetite. Which action does the nurse take to enhance the client's nutritional intake?

A bed-bound chart has a prescription for routine urinalysis. In which way does the nurse obtain the urine sample for the laboratory?