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A nurse is caring for a client whose family member requests to view the client’s medical record. Which of the following responses should the nurse make?

A nurse is assessing a client who is receiving metoprolol. Which of the following indicates a therapeutic effect?

A nurse is providing discharge teaching for a client who has a new prescription for home oxygen. Which of the following instructions should the nurse include in the teaching?

A nurse at a family practice clinic receives a call from a client who is prescribed oral contraceptives but forgot to take one dose. The client reports she is in the first week of a 28-day cycle pack. Which of the following instructions should the nurse provide?

A nurse is caring for a toddler who is 24 hours postoperative following a cleft palate repair. Which of the following actions should the nurse take?

A nurse is assessing a client who is receiving vancomycin. The nurse notes a flushing of the neck and tachycardia. Which of the following actions should the nurse take?

A nurse is caring for a client who has just returned from the PACU after a traditional cholecystectomy. In which of the following positions should the nurse place the client?

A nurse is caring for a client who develops an airway obstruction from a foreign body but remains conscious. Which of the following actions should the nurse take first?

A nurse is caring for a patient on a medical-surgical unit.

Medical History:

•  
• Day 1:                                                                                                                        
  • Parkinson’s Disease
  • Heart failure

Medication Administration Record:

•  
• Day 1:                                                                                                                     
  • Furosemide 40 mg po bid
  • Carbidopa/Levodopa 25 mg/100 mg po tid

Vital Signs:

•  
• Day 1:                                                                                                                    
  • Temperature: 37.2°C (99°F)
  • BP: 128/56 mm Hg sitting, 92/40 mm Hg standing
  • Heart rate: 66/min
  • Respiratory rate: 18/min
  • Pulse oximetry: 96% on room air (95% to 100%)

Diagnostic Results:

•  
• Day 1:                                                                                                                    
  • Hct: 38% (37% to 47%)
  • Hgb: 13 g/dL (12 g/dL to 16 g/dL)
  • WBC: 6,500/mm³ (5,000 to 10,000/mm³)
  • Potassium: 3.5 mEq/L (3.5 mEq/L to 5 mEq/L)
•  
• Day 2:                                                                                                                    
  • Hct: 39% (37% to 47%)
  • Hgb: 14 g/dL (12 g/dL to 16 g/dL)
  • WBC: 7,000/mm³ (5,000 to 10,000/mm³)
  • Potassium: 3.0 mEq/L (3.5 mEq/L to 5 mEq/L)

A nurse is performing a fall risk assessment on a patient. Which of the following findings indicate that the patient is at increased risk for falls? Select all that apply

A nurse is caring for a 73-year-old client in the emergency department (ED).

Medical History: Client was brought to the ED by their family member due to mental status changes. The family member reports that they visit the client every other day, and today the client did not initially realize who they were until several minutes after talking with them. The client has diabetes mellitus and takes insulin daily. A wound is noted on the right foot.

Nurses Notes: Family member reports that the client did not initially realize who they were when they went to visit. Client is currently somnolent but rouses to verbal stimuli and is oriented to person. Glasgow coma score is 13 and Modified Early Warning System (MEWS) score is 6. Respirations are even, unlabored, and deep, with few crackles noted in lung bases bilaterally with auscultation. Mucous membranes are dry and pink. Abdomen soft with hypoactive bowel sounds. Radial and pedal pulses are palpable, no edema noted. Skin is warm and dry. The right foot has a 2.5 cm x 3.3 cm (1 in x 1.3 in) superficial wound to the ball of the foot. The wound is moist with a scant amount of purulent drainage. Client stated they stepped on something last week while walking but did not notice a wound had occurred.

Client’s family member reports that the client takes 10 units of regular insulin subcutaneously every morning and 5 units every evening with the last dose taken this morning. Also states that the client took two aspirin yesterday for a headache.

Vital Signs:

• Temperature: 38.5°C (101.3°F)
• Pulse: 110/min
• Blood pressure: 98/60 mm Hg
• Respiratory rate: 26/min
• Oxygen saturation: 93% on 2 L nasal cannula
•  

Diagnostic Results:

• RBC count: 5.0 (Male 4.7 to 6.1)
• WBC count: 9,500/mm³ (5,000 to 10,000/mm³)
• Platelets: 97,000/mm³ (150,000 to 400,000/mm³)
• Hemoglobin: 15 g/dL (Male 14 to 18 g/dL)
• Hematocrit: 45% (Male 42% to 52%; Female 37% to 47%)
• Glucose: 186 mg/dL (74 to 106 mg/dL)

It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications:

A nurse is triaging clients following a mass casualty event. Which of the following clients should the nurse assess first?