The post anesthesia care unit (PACU) nurse uses the SBAR format in reporting to the surgical unit nurse regarding an older client who had a right total hip replacement for avascular necrosis. Vital signs are reported, which are all stable and within normal limits. The nurse also reports that the client was medicated for pain with morphine 2 mg IV and ondansetron 4 mg IV 45 minutes ago, which reduced the pain level to 4 on a 0 to 10 scale, but the client is still nauseated. Which additional information is critical for the PACU nurse to include in the SBAR format report? Select all that apply.

Patient Data

Which intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.

Four days after exposure to COVID-19 a client has a negative COVID-19 test result. Eight days after the negative test result, the client presents with fever, fatigue, and cough and the nurse performs a second COVID-19 test. Which action is most important for the nurse to take?

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?

In determining the one minute Apgar score of a neonate, the nurse assesses a heart rate of 120 beats per minute and 44 respirations per minute. The neonate has flaccid muscle tone with slight flexion and slight resistance to straightening, a loud cry with stimulation, and acrocyanotic color. Which is the correct Apgar score for this neonate?

A client is admitted for blunt force chest trauma following a motor vehicle collision. A nasogastric (NG) tube was inserted in the emergency department and chest x-ray results indicate that the tip of the NG tube is in the left chest. Which priority action(s) should the nurse implement? Select all that apply.

The post anesthesia care unit (PACU) nurse uses the SBAR format in reporting to the surgical unit nurse regarding an older client who had a right total hip replacement for avascular necrosis. Vital signs are reported, which are all stable and within normal limits. The nurse also reports that the client was medicated for pain with morphine 2 mg IV and ondansetron 4 mg IV 45 minutes ago, which reduced the pain level to 4 on a 0 to 10 scale, but the client is still nauseated. Which additional information is critical for the PACU nurse to include in the SBAR format report? Select all that apply.

Review H and P, nurse's notes, and prescriptions.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

An older adult client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). The client has facial paralysis and cannot move the left side of the body. When entering the room, the nurse finds the client's spouse tearful and trying unsuccessfully to give the client a drink of water. Which action should the nurse take?

The nurse is caring for a client with elevated parathyroid hormone levels. Which safety precaution should the nurse include in the plan of care?

Patient Data

The client is ready for transfer to the neurological intensive care unit (ICU). The receiving nurse obtains report from the emergency department (ED) nurse.

Received a computed tomography (CT) scan of the head 18 gauge peripheral IV (PIV) in bilateral antecubital spaces

CMP, WBC, APTT, PT/INR drawn and results are all WNL

12-Lead ECG normal sinus rhythm (NSR)

0.9% sodium chloride infusing at 50mL/hour

Sitting in a semi Fowler's position

Client is NPO

Pharmacy bringing tissue plasminogen activator (tPA) to the unit shortly

Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided.

During tPA administration, the nurse should prioritize