The unlicensed assistive personnel reports vital signs for a patient to the nurse: Oral Temperature of 99.2 degrees Fahrenheit. Radial pulse of 88 bpm and regular, Respirations of 18 bpm and regular, blood pressure supine in left arm of 178/112 mm Hg. and oxygen saturation of 95% on room air. Which vital sign should the nurse be most concerned about?

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 physician’s admitting orders indicate that the client is to be placed in a High Fowler’s position. Upon positioning this client, how much will the nurse elevate the head of the bed?

A nurse is caring for a comatose patient and applies a hand and wrist roll in each hand of the patient to keep the thumb slightly adducted and correct position to the fingers. What is the primary purpose of this action?

A nurse is caring for a patient who has a low platelet count and is at risk for bleeding. Which of the following is a critical factor or priority that the nurse should apply when considering how to obtain the patient’s vital signs?

The nurse is applying a wrist restraint on a client who has pulled out his IV multiple times. How should the nurse secure this device?

A nurse is ambulating a client who catches her foot on the bed frame and begins to fall. Which of the following is an accurate step to prevent or minimize damage from this fall?

The unlicensed assistive personnel reports vital signs for a patient to the nurse: Oral Temperature of 99.2 degrees Fahrenheit. Radial pulse of 88 bpm and regular, Respirations of 18 bpm and regular, blood pressure supine in left arm of 178/112 mm Hg. and oxygen saturation of 95% on room air. Which vital sign should the nurse be most concerned about?

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 admitting a patient with a suspected tuberculosis infection. Which type of isolation should the nurse institute for this client?