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A client with myasthenia gravis receives a new prescription for pyridostigmine. Which information should the nurse obtain to prior to administering the medication?

In assessing a client's neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?

In preparing to perform colostomy care, the nurse observes that a client's colostomy stoma has become a dark red to bluish color. Which action should the nurse implement?

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 has an IV solution infusing through a catheter inserted in the right antecubital area. The infusion pump is alarming and indicates an occlusion. Which action should the nurse take?

The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?

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?

While assessing placement of a nasogastric tube (NGT), the nurse aspirates cloudy green fluid into a syringe. Which intervention should the nurse implement?

An older adult client recovering from coronary artery bypass surgery becomes weak and dizzy when standing to ambulate in the hall with the unlicensed assistive personnel (UAP). The UAP assists the client back into bed and notifies the nurse of the occurrence. Which intervention is most important for the nurse to include in the client's plan of care?

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)]