While performing a skin assessment on an older adult, the nurse notices a number of irregular, round, brownish-colored lesions on the client's hands, arms, and face. On palpation, they are flat and slightly rough to the touch. Based on this assessment finding, which action should the nurse implement?

During the shift change report, the nurse is told that a client has a stage 2 pressure injury. Which ulcer appearance is most likely to be observed?

The nurse is preparing a bladder irrigation for an adult client who has a long-term indwelling urinary catheter. The urine is cloudy with fibrin clots and sediment. Which intervention should the nurse implement?

Two days after surgery, a client experiences incisional pain while dangling at the bedside and refuses to ambulate as prescribed. The nurse establishes a problem of "Activity intolerance related to pain." Based on this problem, which outcome statement is best for the nurse to include in this client's plan of care?

A client arriving to the emergency department reports trouble breathing and tightness in the chest that started while exercising at the gym. The nurse observes the client is afebrile, heart rate 96 beats/minute, respirations 32 breaths/minute, and pulse oximeter reading of 85%. Audible wheezing is heard on expiration with a decrease in tactile fremitus and bilateral breath sounds. The client displays intercostal retracting and prolonged expirations. Based on the findings, the nurse should recognize the client is exhibiting symptoms of which condition?

An older client is admitted to the medical-surgical unit after falling and fracturing the left hip. The nurse is reviewing written preoperative instructions with the client and spouse. Which action should the nurse implement while providing these instructions?

After receiving large doses of chlorpromazine for two weeks, a client begins to develop spasms of the neck and back. Which action should the nurse take?

The home care nurse has identified the nursing problem, "risk for hopelessness" for a client who is terminally ill with a life expectancy of several days. Which instruction should the nurse provide to the client's spouse?

Which client is at greatest risk for aspiration?

A client who has type 2 diabetes mellitus takes metformin 500 mg PO daily for blood glucose control. The client has been NPO since midnight in preparation for general anesthesia and surgery. At 0700 the client's serum glucose level is 250 mg/dL (13.9 mmol/L). Which action should the nurse implement?

Reference Range:

Fasting Blood Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

To assess a male client's muscle strength, the nurse first asks the client to extend his arms. Before asking the client to flex his arms, what should the nurse do?