A client who performs peritoneal dialysis at home calls the nurse at the dialysis clinic to report pain and tenderness in the abdomen and vomiting since yesterday. Which assessment question is most important for the nurse to ask the client?

The nurse cares for a client with second and third-degree burns covering 40% of their total body surface area (TBSA). When performing a dressing change, which action should the nurse perform?

A client's stump is healing after a below-the-knee amputation, and the client asks the nurse detailed questions about the healing process. What step does the nurse describe when teaching about the inflammatory phase of wound healing?

A client tests positive for vancomycin-resistant enterococci (VRE) in the gastrointestinal tract. Which nursing intervention is the priority in reducing the spread of the organism to other clients in the hospital?

A client was admitted to the neurological unit yesterday with new onset seizures. The seizures have been lasting for just over four minutes, and the nurse is concerned that they may start to last longer. Which prescription should the nurse ensure is written by the health care provider and always on hand for this client?

A client visits the clinic with symptoms of a urinary tract infection (UTI), is diagnosed with a UTI, and is prescribed a course of antibiotic treatment. When the nurse teaches the client about the medication and preventing a subsequent UTI, which statements by the client indicate that the nurse will need to reinforce the teaching? Select all that apply

A client on a mechanical ventilator has experienced the loss of all brain function, confirmed by electroencephalogram (EEG). Before terminating life support, which action should the nurse prioritize considering the legal and ethical issues in end-of-life care?

The nurse is reviewing the client's current lab values. Which situation requires further evaluation?

The health care provider (HCP) removes a client's chest tube at the bedside and accidentally drops the dressing to be used on the floor. The nurse has gone to get another dressing. Which dressing should the nurse bring back to the HCP?

The nurse evaluates a client with a right leg deep vein thrombosis (DVT) to determine if treatment is effective. Which findings indicate that treatment is not therapeutic? Select all that apply.

A client is being treated for an exacerbation of Crohn's disease Which finding leads the nurse to conclude that the client's condition is not improving?

The experienced nurse precepts a graduate nurse in the intensive care unit. Which action by the graduate nurse requires immediate intervention by the experienced nurse?

The nurse cares for a client with Addison's disease who is being treated with hydrocortisone. Which symptoms should the nurse recognize as manifestations of medication overtreatment? Select all that apply.

The nurse educates a family about caring for a client with a below- the-knee amputation due to diabetes mellitus type 2. Which instructions should the nurse include in the client's plan of care?

The nurse is in the room of a client who had a lengthy surgery yesterday. As the nurse speaks with the client, the client suddenly starts to cough, reports difficulty breathing, and is anxious. The nurse places the client in semi-Fowler's position and obtains vital signs. What additional assessment is a priority?

The floor nurse determines the readiness of use for a new arteriovenous fistula placed in preparation for hemodialysis. Which findings inform the nurse that there might be complications preventing the catheter from being used? Select all that apply

A client with diabetic ketoacidosis is given regular insulin via infusion pump. Which electrolyte disturbance should the nurse expect to see following the insulin infusion?

Review the electronic health record Click to highlight the nursing note entry that could result in the most harm to the client Nursing Notes 8/10 0850: Client off unit for radiation. 1115: Client returned from radiation and reports burning at radiation site. Site observed to be dry and red without signs of infection. 1220: Client eating lunch without complaints. 1330: Unlicensed assistive personnel reports client consumed 20% of lunch tray. 1400: Client's son visiting at bedside. Observed son applying heating pad to client's radiation site per client request. 1435: Intravenous chemotherapy initiated via infusion pump. Client tolerating initiation. 1500: Client assessed. Reporting nausea. 8 mg ondansetron administered intravenously. 1530: Client continues to tolerate chemotherapy infusion with no change in vital signs. Nausea resolved. Client resting with eyes closed and respirations even.

The nurse participates in a humanitarian aid trip, providing care to residents of a tent city in Haiti. Which additional signs and symptoms is the nurse likely to find and document at 0900? Select all that apply

At the end of the shift, the nurse rounds on assigned clients after receiving report from the unlicensed assistive personnel (UAP). Which observation of the client's indwelling urinary catheter system prompts the nurse to follow up with the UAP?

The nurse receives report from the emergency department about a client being admitted to the floor with pancreatitis. As the nurse prepares for the client to arrive, what should the nurse include in the plan of care? Select all that apply.

The nurse cares for a client being treated for cardiogenic shock after a left ventricular myocardial infarction. Which assessment finding indicates the client is improving?