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.

A client is admitted with the diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use when developing the client's plan of care?

Patient Data

The nurse administered tPA and conducted neurologic assessments every 15 minutes during the infusion. The tPA infusion finished and the nurse performed neurologic assessments every 30 minutes for the 6 hours following the administration. The client was noted to be stable with unchanged neurologic assessments. The nurse begins to plan care for the client's recovery and identifies interdisciplinary team members who can assist with the client's recovery.
Which interdisciplinary team member(s) should assist the client in recovery? Select all that apply.

A client diagnosed with Parkinson's disease receives a prescription for carbidopa-levodopa, controlled release (CR) 25/100 mg PO daily each morning. Which information should the nurse include in the client's teaching plan? Select all that apply.

Patient Data

The nurse uses the Modified Caregiver Strain Index (MCSI) and determines that the daughter is under significant stress caused by the assumption of her mother's care. The nurse is planning to have a discussion with the daughter on decreasing the stress she is experiencing as a caregiver.
Select the 3 statements that the nurse should include when discussing caregiver stress with the client's daughter.

A client with chronic kidney disease (CKD) has an arteriovenous (AV) fistula in the left forearm. Which observation by the nurse indicates that the fistula is patent?

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?

An older female client who resides at an assisted living facility comes for an annual gynecological visit at the clinic and states she has a burning sensation when urinating. Assessment findings include: blood pressure 128/88 mm Hg, urine negative for bacteria, and ecchymotic areas on both forearms. She reports being sexually active and drinks beer once or twice a month. During this clinic visit, which intervention(s) should the nurse implement? Select all that apply.

A client who has been taking colchicine calls the clinic with reports of an acute gout attack of the right great toe. The client has a history of kidney stones and esophageal reflux. Which finding warrants immediate intervention by the nurse?

A female client with breast cancer is scheduled to receive a series of radiotherapy (RT). She has red hair, fair skin, and freckles. She tells the nurse that her skin is particularly sensitive to the sun, so she is worried that the radiation will adversely affect her skin. Which information should the nurse provide this client about RT? Select all that apply.

In caring for a client with chronic kidney disease (CKD), the nurse notes that the client's serum phosphate level is elevated, with a converse decrease in serum calcium. Which nursing care goal is a priority, based on these laboratory findings?