Which of the following would be falsification of health records? Select all that apply.

A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient's legs, the nurse documents: Pitting edema; 8-mm pit. Pit remained for 4 minutes after pressing. What grade of edema has this nurse documented?

A nurse is managing a patient's fluids and outputs over a shift. Here are the details:

• 0700: The nurse starts an IV of 0.45% Normal saline infusing at 100 mL/hr.
• 0900: The patient has coffee-ground emesis (vomit) measuring 300 mL.
• 1000: The nurse stops the IV of 0.45% Normal saline to administer an IV antibiotic. The antibiotic administered is Kefzol 1 g in 25 mL of D5W over 30 minutes.
• 1030: The antibiotic infusion stops, and the nurse resumes the IV fluid of 0.45% Normal saline at 100 mL/hr.
• 1100: The physician orders the insertion of an NG tube and intermittent suction. The nurse inserts the NG tube and connects it to intermittent suction.
• 1530: The patient voids another 350 mL and 200 mL. The nurse checks the NG tube canister and records the output for the shift as 300 mL.

Calculate the patient's total intake from 0700 to 1530.

Upon responding to the client's call bell, the nurse discovers the client's abdominal wound has been eviscerated. Initial nursing management includes calling the healthcare provider and which other initial action?

A nurse notes that a client is confused, impulsive, and unstable with mobility. The nurse fears the client is in danger of harming themselves so they ask for a sitter to stay at the bedside to keep the client company and minimize the risk for falls. What ethical principle is the nurse demonstrating?

The physician orders penicillin G 1,000,000 units IM. The label on the vial of powdered penicillin G reads to reconstitute with 1.6 mL of sterile water to achieve a concentration of 5,000,000 units/mL.

How many mL will the nurse give to the client for the ordered dose?

A new perioperative nurse is being educated regarding surgical asepsis. What observations by the preceptor would indicate that there is a need for further education and reinforcement of the principles of asepsis?

The nurse is caring for a patient who is confused and agitated. The patient continues to get out of bed without assistance and is at high risk for falls. The nurse is considering alternatives to implement prior to applying restraints.

Of the following, which would the nurse NOT consider in the plan of care as an alternative to restraints?

A nurse can most accurately assess a client's apical heart rate by which of the following methods?

The home health nurse notes the client has gained 5 pounds overnight and has increased edema in the lower extremities. The nurse is calling the physician to obtain an order over the phone for furosemide medication. The physician gives an order and the nurse enters the order in the client's medical record. What will the nurse do next after writing down the order?

A nurse is caring for an alert and oriented client who has terminal lung cancer. The nurse observes the client's family assisting with all ADLs. Which of the following rationales for self-care should the nurse communicate to the family on behalf of the client?