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The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results. Which diagnostic test should the nurse review to confirm the diagnosis of TB?

The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

A client receives a prescription for ophthalmic ketorolac. Prior to administering the medication, the nurse should review the medical record for which condition?

The antitubercular drug isoniazid is prescribed for a client with active tuberculosis. To evaluate the effectiveness of this medication, which outcome can the nurse expect this client to exhibit?

Three days after a cholecystectomy for cholelithiasis, a female client reports having persistent upper abdominal pain that radiates to her back. Based on these findings, the nurse should observe the client for which pathophysiological condition?

Exhibit 1: History and Physical

The client is a 51-year-old male admitted to the medical floor with a diagnosis of pneumonia. He reports a 3-day history of productive cough, shortness of breath, and fever. He also mentions increased fatigue and weakness over the last week. The client has a history of hypertension, which is controlled with enalapril 10 mg daily. His surgical history includes adenoidectomy at age 5 and surgical repair of a fractured femur at age 20. The client takes a multivitamin daily and has no known allergies. He is a non-smoker and reports occasional alcohol use.

Exhibit 2: Nurse's Notes (0800)

At 0800, the client was alert but appeared fatigued and short of breath. His oxygen saturation was 89% on room air, and he was placed on supplemental oxygen at 10 L/min via nasal cannula, which improved his saturation to 94%. The client stated, “I feel tired and weak, and it’s hard to breathe.” His skin was warm to the touch, and he had a productive cough with thick, yellow sputum. He reported a headache and body aches, rating his pain as 4/10. The client denied chest pain but reported feeling feverish throughout the night. His capillary refill was less than 3 seconds, and lung sounds were diminished with crackles heard bilaterally.

Exhibit 3: Vital Signs

• Time: 0800
• Temperature: 101.2°F (38.4°C)
• Pulse: 112 beats per minute
• Respiratory Rate: 28 breaths per minute
• Blood Pressure: 150/92 mmHg
• Oxygen Saturation: 89% on room air, 94% on 10 L/min nasal cannula

Exhibit 4: Physical Examination Results

Upon physical examination, the client appeared ill and was in mild respiratory distress, with shallow and rapid breathing. His skin was warm and flushed, and he was diaphoretic. Lung auscultation revealed bilateral crackles in the lower lobes, more pronounced on the right side. There were no wheezes or rhonchi noted. His heart sounds were regular, but tachycardia was present. The client’s abdomen was soft and non-tender with normal bowel sounds. No edema was noted in the extremities, and there were no visible rashes or skin abnormalities. The client’s capillary refill was normal, and neurological assessment showed no focal deficits.

Exhibit 5: Provider's Prescriptions

1. Admit to the medical floor
2. Vital signs every 4 hours
3. Continuous pulse oximetry
4. Supplemental oxygen 10 L/min via nasal cannula
5. Enalapril 10 mg PO every morning
6. Ibuprofen 400 mg PO every 4 to 6 hours PRN for temperature greater than 100.5°F (38.0°C)
7. Send blood for complete blood count and electrolytes
8. Chest X-ray now

Question: Which of the following provider's prescriptions would the nurse question? Select all that apply.

A client who has had a laryngectomy and tracheostomy frequently expectorates copious amounts of purulent secretions. When changing the ties of the tracheostomy tube, which action is most important for the nurse to take?

Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to eat plenty of dairy products to help coat and protect the duodenal ulcer. Which is the best follow-up action by the nurse?

While changing a client’s postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client’s laboratory values?

A client with open-angle glaucoma asks the nurse how long the prescribed eye drops will need to be used. Which response made by the nurse is accurate?