Following a motor vehicle accident, a client with chest trauma receives a chest tube to relieve a hemothorax. Two hours following the chest tube insertion, the nurse observes the water level in the water-seal chamber is rising during inspiration and falling during expiration. Which action should the nurse implement?

A client with a cervical spinal injury (C7) is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor?

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?

Lactulose was prescribed two days ago for a client who was recently diagnosed with hepatic encephalopathy. The client is confused and experiencing frequent loose stools. Laboratory findings show an elevated serum ammonia (NH) level of 220 μg/dL (157.1 μmol/dL). Which action should the nurse take? Reference Range: Ammonia [10 to 80 μg/dL (6 to 47 μmol/L)]

The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this disease process?

A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?

The nurse is caring for a client receiving thrombolytic therapy following an acute myocardial infarction (MI). Which nursing problem should the nurse identify as priority for this client?

The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?

An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rales and wheezing. When assessing this client, which additional finding is the nurse likely to obtain?

A client with a right ulnar fracture and cast placement reports an increase in arm pain. Which action should the nurse take next?

A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and palpitations. Which finding is most important for the nurse to monitor?

A client asks the nurse for information about how to reduce risk factors for benign prostatic hyperplasia (BPH). Which information should the nurse provide?

In assessing a client with skin ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin?

A family suspects that AIDS dementia is occurring in their adult child who is HIV positive. Which symptom confirms the suspicion?

Five months following treatment for herpes zoster, an older adult client tells the home health nurse of continuing to experience pain where the rash occurred. Which action should the nurse implement?

A client who reports feeling chronically fatigued has a hemoglobin of 10 g/dL (110 mmol/L). hematocrit of 34% (0.34 volume fraction), and microcytic and hypochromic red blood cells (RBCs). Based on these findings, which dinner selection should the nurse suggest to the client? Reference Range. Hemoglobin (Hgb) [16 to 18 g/dL (160 to 180 g/L)] Hematocrit (Hct) [42% to 52% (0.42 to 0.52 volume fraction)] 9000

A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the postanesthesia unit. Before selecting which medication to administer, which action should the nurse implement?

A client who had a biliopancreatic diversion procedure (BDP) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse?

A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?

A client with metastatic cancer reports a pain level of 10 on a scale of 0 to 10. Twenty minutes after the nurse administers an IV analgesic, the client reports no pain relief. Which intervention is most important for the nurse to include in this client's plan of care?

In providing discharge teaching to a client with chronic obstructive pulmonary disease (COPD), which instruction is most important for the nurse to emphasize?

While completing a health assessment for a young adult female with acute appendicitis, the client informs the nurse that there is a chance that she may be pregnant. The operating team is preparing to take the client to surgery. Which intervention should the nurse implement immediately?

The nurse is evaluating a client's understanding of diet teaching about the DASH (Dietary Approaches to Stop Hypertension) eating plan. Which behavior indicates that the dient is adhering to the eating plan?