Which situation indicates a need for the nurse to discuss the use of mitten restraints with the healthcare provider?

A client with Neisseria meningitidis calls the nurses station to report a severe headache and vomiting. The unlicensed assistive personnel (UAP) approaches the room to provide an emesis basin and is stopped by the nurse. Which action should the nurse take?

The nurse is caring for a client who is immobile and developed a stage IV pressure injury on the sacrum. The nurse identifies eschar in the wound bed. Which intervention is most important for the nurse to implement?

When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse?

During shift report, the charge nurse receives notice of several problems. Which problem should the nurse address first?

The nurse is caring for a client with left-sided hemiparesis after a stroke. Which action should the nurse take to safely assist the client with ambulation?

A group of nurses implement a pilot study to evaluate a proposed evidence-based change to providing client care. Evaluation indicates successful outcomes and the nurses want to integrate the change throughout the facility. Which actions should be taken? Select all that apply.

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 female adult who works in the mailroom of an ammunitions plant opened an envelope that contained a white powder. Believing that she might have been exposed to anthrax, the client is immediately transported to the emergency department (ED) of a local hospital. Which intervention(s) in the emergency disaster response plan should the nurse implement? Select all that apply.

The nurse reviews the clinical findings.

For each of the findings listed, click to indicate which are consistent with the disease process of major depressive disorder, generalized anxiety disorder, or posttraumatic stress disorder. Each column must have at least one response selected.

An older adult client with emphysema who continues to smoke cigarettes returns to the medical unit after a physical therapy session, and is short of breath. The nurse notes that the client is lying supine with the head of the bed elevated to 45 degrees. Oxygen is flowing via nasal cannula at 3L/minute. The client's pulse oximetry is 88%, respiratory rate is 14 breaths/minute, and vital signs are stable. Which intervention should the nurse implement?