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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?

 

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?

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 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 administering the muscle relaxant baclofen by mouth (PO) to a client diagnosed with multiple sclerosis. Which intervention should the nurse implement?

When entering a client's room to assess vital signs, the nurse finds the client crying. After allowing the client to express feelings, which intervention should the nurse implement?

A client with type 2 diabetes mellitus (DM) who normally takes an oral antidiabetic agent asks the nurse why insulin is necessary during this hospitalization for chronic obstructive pulmonary disease (COPD) exacerbation and pneumonia. Review of the medication record indicates the client is taking methylprednisolone, clindamycin, and pioglitazone. How should the nurse respond?

A parent brings a preteen daughter to the clinic for her first female examination. During the health assessment, the nurse should implement which technique to determine if the client has reached the age of menarche?

The nurse is caring for a client with hypertension, gastroesophageal reflux, and osteoarthritis. While performing a bedside assessment the nurse observes the client is alert and oriented, but is exhibiting signs of jaundice. The nurse should notify the healthcare provider about which scheduled medication?

A client is being evaluated for environmental allergies. While examining the client's nasal passage, which finding suggests to the nurse that the client is experiencing allergic rhinitis?

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?