My Comp Review Question

A charge nurse is concerned about a recent increase in facility-acquired catheter Infections. Which of the following actions should the nurse take first? Identify possible precipitating factors related to the infections. A charge nurse is concerned about a recent increase in facility-acquired catheter infections. Which of the following actions should the nurse take first? Identify possible precipitating factors related to the infections. A charge nurse is monitoring a newly licensed nurse who is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following statements by the newly licensed nurse indicates an understanding of the procedure? "I will hang a new bag of TPN and IV tubing every 24 hours." A charge nurse is observing a newly licensed nurse provide care for a client who is postoperative. The newly licensed nurse tells the client that she will insert a urinary catheter if the client will not void. Which of the following torts should the charge nurse Identify as having occurred? Assault A charge nurse is teaching a newly licensed nurse about medication administration. Which of the following information should the charge nurse include? Inform clients about the action of each medication prior to administration. A charge nurse is teaching a newly licensed nurse about the facility's computerized documentation system. Which of the following information should the nurse include? "Information Technology will install a firewall to secure client information." A charge nurse is teaching new staff members about factors that increase a client's risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence? Previous violent behavior A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge? A client who is 1 day postoperative following a vertebroplasty. A community health nurse is working with a family that is struggling to adapt following the loss of a family member. Which of the following actions should the nurse take first? Determine the roles of individual family members. A community health nurse is working with a group of clients. The nurse practices the ethical principle of distributive Justice by performing which of the following tasks? Ensuring that a client who is homeless receives preventive medical care A home care nurse is making a follow-up visit with a client who has COPD and is using a compressed oxygen system in his home. Which of the following actions should the nurse take? Place the oxygen tank away from curtains or drapes. A home health nurse is assessing a client who has amyotrophic lateral sclerosis (ALS) and has had recent weight loss. Which of the following is the priority admission data for the nurse to obtain? Swallowing ability A home health nurse is caring for a child who has Lyme disease. Which of the following is an appropriate action for the nurse to take? Ensure the state health department has been notified. A home health nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care? Place locks at the tops of exterior doors. A home nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan monitor? Serum sodium and potassium A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make? "I can give you information about respite care if you are interested." A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse Identify as tertiary prevention? Using an electronic messaging system to remind clients when to take medications A nurse and an assistive personnel (AP) are assigned a group of clients on the unit. Which of the following clients should the nurse instruct the AP to report to the nurse? A client who has a prescription for compression stockings and did not receive them. A nurse enters a client's room and sees a small fire in the client's bathroom. Identify the sequence of steps the nurse should take. (Move the steps, placing them in the order of performance. Use all the steps.) A Transport the client to another area of the nursing unit. B Activate the facility's fire alarm system. C Close all nearby windows and doors. D Use the unit's fire extinguisher to attempt to put out the fire. A nurse has identified tasks to delegate to a group of assistive personnel (AP) after receiving change-of-shift report. Identify the sequence of steps the nurse should follow when delegating tasks to the APs. (Move the steps, placing them in the selected order of performance. Use all the steps.) B: Review the skill level and qualifications of each AP. C: Communicate appropriate tasks to the APs with specific expectations. A: Monitor progress of task completion with each AP. D: Evaluate the APs' performance of each task A nurse in a family health clinic is caring for a client who requests information regarding the correct use of condoms. Which of the following statements should the nurse make? "When using implanted contraceptive methods, condoms should also be used to protect against STDs A nurse in a long-term care facility is admitting a client who has dementia. Which of the following actions should the nurse take to reduce the risk for client injury? Assist the client to the toilet frequently A nurse in a long-term care facility is admitting a client who has dementia. Which of the following actions should the nurse take to reduce the risk for client injury? Assist the client to the toilet frequently. A nurse in a prenatal clinic is teaching a client about nonpharmacological pain management during labor. Which of the following statements by the client indicates an understanding of the teaching? "I can use my ultrasound picture as a focal point during contractions." A nurse in an acute care mental health facility is participating in a medication education group. The leader of the group uses a laissez-faire leadership style. Which of the following actions should the nurse expect from the leader during the session? The leader allows the group to discuss whatever they would like to regarding their medications. A nurse in an acute care mental health facility is placing a client in seclusion and restraints. Which of the following actions should the nurse plan to take? Document the client's behavior every 15 min. A nurse in an acute mental health care facility is prioritizing care for multiple clients. Which of the following clients should the nurse see first? A client who is taking clozapine to treat schizophrenia and reports a sore throat A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets 20 min ago. The client is lethargic and a respiratory rate of 10/min. After securing the client's airway and initiating an IV, which of the following actions should the nurse take next? Administer flumazenil to the client A nurse in an emergency department is assessing an adolescent who has conduct disorder? Which of the following questions is the priority for the nurse to ask the client? Do you have thoughts of harming yourself A nurse in an emergency department is caring for a 3-year-old child who has suspected epiglottitis. Which of the following actions should the nurse include in the plan nurse take? Prepare to assist with intubation. A nurse in an emergency department is caring for a client who is actively bleeding from a stab wound to the thigh. Which of the following actions should the nurse take? Apply direct pressure to the wound with thick dressing material. A nurse in an outpatient mental health clinic is assessing an adolescent client. The nurse should expect the adolescent to be in which of the following of Erikson's stages of psychosocial development? Identity vs role confusion A nurse in PACU is transferring care of a client to a nurse on a medical-surgical unit. Which of the following statement should nurse include in the hand off report? The estimated blood loss was 250milliters A nurse in the emergency department is assessing a newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following actions should the nurse take first? Apply 100% humidified oxygen. A nurse in the emergency department is receiving report on a group of clients. Which of the following clients should the nurse assess first? A client who has left shoulder pain and S-T elevation on a 12-lead ECG A nurse inadvertently administers 160 mg of valsartan PO to a client who was scheduled to receive 80 mg. Which of the following actions is the priority for the nurse to take? Evaluate the client for orthostatic hypotension A nurse is admitting a client to a medical-surgical unit. When performing medication reconciliation for the client, which of the following actions should the nurse take? Compare new prescriptions with the list of medications the client reports. A nurse is admitting a client who has acute heart failure. Which of the following prescriptions from the provider should the nurse anticipate? Administer enalapril 2.5 mg PO twice daily. A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding. The nurse speaks a different language than the client. The client's partner and 10- year-old child are accompanying her. Which of the following actions should the nurse take to gather the client's admission data? Request a female interpreter through the facility. A nurse is admitting a client who is hesitant to create advance directives due to concerns about affording legal representation. Which of the following statements should the nurse make?“Advance directives can be signed without legal representation." A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the client's coccyx and abrasions around both wrists. Which of the following actions should the nurse take to address suspicions of elder abuse? Privately interview the client about the injuries. A nurse is assessing a 2-year old toddler. Which of the following finding should the nurse expect? Nontender protruding abdomen A nurse is assessing a 5-year-old child who has diabetes insipidus and is receiving desmopressin. Which of the following findings should the nurse identify as an indication that the medication is effective? Cessation of nocturnal enuresis A nurse is assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect? Fever A nurse is assessing a client following an esophagogastroduodenoscopy. Which of the following findings should the nurse report to the provider? Abdominal pain A nurse is assessing a client who has a chest tube with a water seal drainage system. Upon assessment, the nurse notes tidaling in the water seal. Which of the following is an explanation for the tidaling? The system is working properly. A nurse is assessing a client who has bipolar disorder and is experiencing a depressive episode. Which of the following findings should the nurse expect? Inability to carry out a simple task A nurse is assessing a client who has histrionic personality disorder. Which of the following manifestations should the nurse expect? Self-centered behavior A nurse is assessing a client who has left-sided heart failure. Which of the following finding should the nurse identity as a manifestation of pulmonary congestion? Frothy pink sputum A nurse is assessing a client who has obsessive-compulsive personality disorder. Which of the following findings should the nurse expect? Goal-oriented A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV Infusion. For which of the following therapeutic effects should the nurse monitor the client? Negative clonus A nurse is assessing a client who has type 1 diabetes mellitus and was. Which of the following clients should the nurse instruct the staff to indicates that the client might be experiencing hypoglycemia? Confusion A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider? FHR baseline 170/min A nurse is assessing a client who is in skeletal traction for a fractured left tibia. The nurse should identify that which of the following findings indicates altered tissue perfusion of the affected extremity? Faint pedal pulse of left leg A nurse is assessing a client who is postoperative and has a history of pulmonary embolism. Which of the following findings is the priority for the nurse to report to the provider? Dyspnea A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr. Which of the following interventions should the nurse anticipate? A nurse is assessing a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate 4 hr ago. The nurse notes pink-tinged urine in the drainage bag. Which of the following actions should the nurse take? Maintain the irrigation solution rate. A nurse is assessing a client who received hydromorphone 4 mg IV 15 min ago. The client has a respiratory rate of 10/min. The nurse should prepare to administer which of the following medications? Naloxone A nurse is assessing a client who received hydromorphone 4 mg IV 15 min ago. The client has a respiratory rate of 10/min. The nurse should prepare to administer which of the following medications? Naloxone A nurse is assessing the coping strategies of a client who has recently retired. Which of the following statements by the client indicates that the client is using compensation as a defense mechanism? "Since I retired, I have entered many gardening competitions." A nurse is assessing the fontanels of an 8-month-old infant. Which of the following findings should the nurse recognize as an expected finding?The anterior fontanel is open. A nurse is assessing the fontanels of an 8-month-old infant. Which of the following findings should the nurse recognize as an expected finding? The posterior fontanel is open. A nurse is assessing the grief response of a client whose child died 6 months ago. Which of the following client statements should the nurse report to the provider as an indication of major depressive disorder? "I am unable to feel any joy since my child died." A nurse is assessing the peripheral catheter insertion site of a client who is receiving an infusion. The nurse notices redness and warmth to the touch around the insertion site. The nurse should document the finding as which of the following complications? Phlebitis A nurse is assessing the skin turgor of an older adult client. In which of the following areas should the nurse lift the skin? Sternum A nurse is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP? Perform postmortem care. A nurse is building a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse plan to take during the orientation phase of the relationship? Establish the responsibilities of the nurse and client. A nurse is caring for a 1-day-old newborn who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take? Ensure that the newborn wears a diaper. A nurse is caring for a 30-month-old child. Which of the following activities should the nurse expect the child to participate in? Playing with dress-up clothes A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take? Perform the procedure prior to meals. A nurse is caring for a child who reports migraine headaches for the past 4 months. Which of the following actions should the nurse take first? Review the child's electronic pain diary. A nurse is caring for a client receiving mechanical ventilation via an endotracheal (ET) tube. The high-pressure alarm is beeping, and the client is experiencing respiratory distress. The nurse is unable to determine the cause of the alarm. Which of the following actions should the nurse take? Deliver breaths manually with a resuscitation bag. A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make? "Your desire to be an organ donor must be documented in writing." A nurse is caring for a client who experienced a traumatic brain injury 72 hour ago. Which in the client's findings are potential indication of increased intracranial pressure? Increasingly severe headache A nurse is caring for a client who has a new diagnosis of Chlamydia trachomatis. Which of the following actions should the nurse take? Report the infection to the state department of health. A nurse is caring for a client who has a new diagnosis of schizophrenia and a prescription for an antipsychotic medication. The nurse should recognize that which of the following indicates an adverse effect that must be reported to the provider? The client is observed displaying a shuffling gait while walking in the hall. A nurse is caring for a client who has a placenta previa. Which of the following findings should the nurse expect? Spotting A nurse is caring for a client who has a prescription for 1 unit of packed RBCs. Five minutes after beginning the transfusion, the client becomes febrile with chills. After stopping the transfusion, which of the following actions should the nurse take? Document the reaction in the medical record. A nurse is caring for a client who has a prescription for a peripheral IV catheter. After puncturing the skin with the vascular access device and noting a blood return in the flashback chamber, which of the following actions should the nurse perform next? Advance the catheter into the vein A nurse is caring for a client who has a stool culture that is positive for Clostridium difficile. Which of the following infection control precautions should the nurse take? Remove the protective gown while in the client's room A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following actions should the nurse perform first? Evaluate functioning of the suction device A nurse is caring for a client who has an NG tube with intermittent suction. Which of the following actions should the nurse take? Flush the tube with 0.9% sodium chloride. A nurse is caring for a client who has cancer and is terminally ill. The client reports feeling depressed. Which of the following statements should the nurse make? Would you like to speak to a spiritual advisor?" A nurse is caring for a client who has diabetes mellitus and is receiving long-acting daily insulin for blood glucose management. The nurse should anticipate administering which of the following types of insulin? Glargine insulin A nurse is caring for a client who has diarrhea and is receiving intermittent enteral feedings. Which of the following actions should the nurse take? Administer feedings at a slower rate. A nurse is caring for a client who has end-stage kidney disease. The client's adult child asks the nurse about becoming a living kidney donor for their parent. Which of the following conditions in the child's medical history should the nurse Identify as a contraindication to the procedure? Hypertension A nurse is caring for a client who has experienced a stillbirth. Which of the following actions should the nurse take during the initial grieving process? Offer to take pictures of the newborn for the client. A nurse is caring for a client who has Graves' disease and is experiencing a thyroid storm. Which of the following actions is the nurse's priority? Monitor the client's cardiac rhythm. A nurse is caring for a client who has heart failure. Which of the following manifestations should the nurse expect? Weight gain A nurse is caring for a client who has heart failure. Which of the following manifestations should the nurse expect? Reduced right-sided breath sounds A nurse is caring for a client who has heart failure. Which of the following manifestations should the nurse expect? Crackles in lungs A nurse is caring for a client who has pneumonia and tells the nurse, "I feel like an elephant is sitting on my chest." The client is weak and unable to walk. After the nurse initiates chest pain protocol, which of the following is the priority diagnostic test? 12-lead ECG A nurse is caring for a client who has respiratory depression from an opioid administration. After administering naloxone to the client, which of the following findings should the nurse expect? Increased pain A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take? Protect the IV bag from exposure to light. A nurse is caring for a client who has systemic lupus erythematosus. Which of the following client findings should the nurse expect? Raised facial rash A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? (Select all that apply.) Keep objects in the client's room in the same place. Approach the client from the side. Ensure there is high-wattage lighting in the client's room. Allow extra time for the client to perform tasks. Touch the client gently to announce presence. A nurse is caring for a client who is 1 hr postpartum and unable to urinate. Which of the following actions should the nurse take? Place an ice pack on the client's perineum. A nurse is caring for a client who is alert and oriented and is receiving continuous ECG monitoring. The cardiac rhythm strip shows a wavy baseline, no distinguishable P waves, and an increased heart rate. The nurse should identify the cardiac rhythm as which of the following? Atrial fibrillation A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications?Contractions A nurse is caring for a client who is being discharged home following a total hip arthroplasty. Which of the following findings in the home should the nurse Identify as a potential risk for Injury? Large soaking tub without a shower head A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis following a stroke. Which of the following actions by the nurse best promotes communication among staff caring for the client? Having interdisciplinary team meetings for the client on a regular basis A nurse is caring for a client who is experiencing Increased Intracranial pressure following a head Injury. In which of the following positions should the nurse place the client? Low-Fowler's A nurse is caring for a client who is experiencing status epilepticus. Which of the following medications should the nurse expect to administer? Lorazepam A nurse is caring for a client who is febrile. To reduce the client's fever, the nurse applies a cooling blanket. Which of the following findings indicates the client is having an adverse reaction to the cooling? Shivering A nurse is caring for a client who is in a coma and is scheduled for a surgical procedure. Which of the following actions should the nurse take? Determine if the client's health care surrogate is aware of the risks and benefits of the procedure. A nurse is caring for a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia? Maternal hypoglycemia A nurse is caring for a client who is in active labor. The nurse should notify the provider for which of the following findings? Prolonged decelerations A nurse is caring for a client who is in labor and notes that the umbilical cord is prolapsed. Which of the following actions should the nurse take? Place the client in Trendelenburg position. A nurse is caring for a client who is in the active phase of labor and has decided to have a natural childbirth. Which of the following pain management techniques should the nurse suggest? Provide information about the use of hydrotherapy during labor. A nurse is caring for a client who is near the end of life and is on complete bed rest. The client states that he needs to have a bowel movement and the nurse offers a bedpan. The client states, "I've always used the bathroom." Which of the following responses should the nurse make? Tell me what concerns you have about using a bedpan." A nurse is caring for a client who is near the end of life and is on complete bed rest. The client states that he needs to have a bowel movement, and the nurse offers a bed pan. The client states, "I've always used the bathroom." Which of the following responses should the nurse make? "Tell me what concerns you have about using a bed pan." A nurse is caring for a client who is on bed rest. The nurse should recognize that which of the following findings is a complication of immobility? Swollen area on calf A nurse is caring for a client who is postoperative following total hip arthroplasty. Which of the following actions should the nurse take to prevent dislocation of the prosthesis? Keep an abduction pillow between the client's legs. A nurse is caring for a client who is receiving brachytherapy for endometrial cancer. Which of the following actions should the nurse take? Keep visitors at least 6 feet (1.8 m) away from the client. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following factors places the client at risk for aspiration? A history of gastroesophageal reflux disease. A nurse is caring for a client who is receiving radiation therapy and is experiencing anorexia. Which of the following actions should the nurse take? Provide the client with cold foods rather than hot foods. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The bag has 20 mL remaining to infuse, but a new bag is not readily available. Which of the following actions should the nurse take? Administer dextrose 10% in water A nurse is caring for a client who is recovering from a cerebrovascular accident in a rehabilitation facility. The client tells the nurse, "I am sick of being in here, and I want to go home." Which of the following responses should the nurse make? It must be very frustrating for you to be here." A nurse is caring for a client who received 50,000 units of IV heparin rather than the prescribed 5,000 units. Which of the following actions should the nurse take first? Check the client for indications of bleeding. A nurse is caring for a client who refuses a blood transfusion. Which of the following actions should the nurse take? Document the client's refusal in the medical record. A nurse is caring for a client who reports a headache and has a history of a peptic ulcer. Which of the following medications should the nurse administer? Acetaminophen A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take? Document the client’s behavior prior to being placed in seclusion. A nurse is caring for a client who speaks a different language than the nurse and is using an interpreter. Which of the following actions should the nurse take when working with the interpreter? Speak in a normal voice at a natural pace. A nurse is caring for a client who speaks a different language than the nurse and is using an interpreter. Which of the following actions should the nurse take when working with the interpreter? A Speak in a normal voice at a natural pace. A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu. The nurse should recognize which of the following findings as a potential contraindication for using lavender? The client has a history of alcohol use disorder. A nurse is caring for a client whose child died from cancer. The client states, "It's hard to go on without him." Which of the following questions should the nurse ask the client first? "Are you thinking about ending your life?" A nurse is caring for a client whose partner died in a fire that destroyed their home. Which of the following action the nurse should take first? Determine if the client has thoughts of self harm A nurse is caring for a male client who has a spinal cord injury. Which of the following techniques should the nurse use when providing perineal care? Discard the washcloth after cleansing the urethral meatus. A nurse is caring for a newborn whose mother was taking methadone during her pregnancy. Which of the following findings indicates the newborn is experiencing withdrawal? Hypertonicity A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage? Use an albuterol inhaler. A nurse is caring for an adolescent who has hyperthermia. Which of the following actions should the nurse take? Initiate seizure precautions A nurse is caring for an adult client who has chronic anemia and is scheduled to receive a transfusion of 1 unit of packed RBCs. Which of the following actions should the nurse take? Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion. A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding? Weak femoral pulses A nurse is completing an admission assessment for a client who has narcissistic personality disorder. Which of the following findings should the nurse expect? Preoccupied with aging A nurse is conducting an initial assessment of a client and notices a discrepancy between the client's current IV infusion and the report received during the shift report. Which of the following actions should the nurse take? Compare the current infusion with the prescription in the client's medication record. A nurse is consulting a pharmacological reference about medication compatibility prior to administering warfarin to a client. Which of the following medications should the nurse identify as being incompatible with warfarin? Naproxen A nurse is contributing to the plan of care for a client who has multiple sclerosis. The nurse should recommend including which of the following interventions in the plan of care to assist the client in overcoming barriers related to this condition? Provide the client with large-handled eating utensils. Establish an alterative to verbal conversation A nurse is creating a plan of care for a client who has cancer and is experiencing Immunosuppression. Which of the following Interventions should the nurse include in the plan of care? Inspect the client's mouth every 8 hr. A nurse is creating a plan of care for a client who has paranoid personality disorder and refuses to take their medication. Which of the following interventions should the nurse include in the plan? Speak in a neutral tone when addressing the client. A nurse is developing a care plan for a client who is in Buck’s traction and is scheduled for surgery for a fractured femur of the right leg. Which of the following interventions should the nurse delegate to an assistive personnel? Remind the client to use the incentive spirometer A nurse is developing a nutritional care plan for a client who has COPD and severe dyspnea. To promote intake, which of the following actions should the nurse include in the plan of care? Limit fluid intake with meals. A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan? Ask the client directly what he is hearing. A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan? Minimize noise in the newborn's environment. A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder? The client exhibits impulsive behavior." A nurse is discussing discharge plans with an older adult client who lives alone and has left-sided weakness following a stroke. Which of the following information is the priority for the nurse to discuss? Obtaining an alert system to get help in case of a fall A nurse is discussing treatment options with a client who is experiencing nicotine withdrawal. Which of the following Information should the nurse include in the teaching? Limit use of nicotine gum to 6 months. A nurse is discussing weight loss with a client who is concerned about losing 6.8 kg (15 lb) from an original weight of 90.7 kg (200 lb). The nurse should identify the weight loss as which of the following total percentages? 7.5 A nurse is evaluating the laboratory values of a client who is receiving epoetin alfa. Which of the following findings indicates a therapeutic response to the medication? Increased hemoglobin level A nurse is giving an intramuscular injection to a newborn who was delivered at 38 weeks of gestation. Which of the following pain scales should the nurse use to assess the newborn's pain? Neonatal Infant Pain Scale (NIPS) A nurse is implementing seizure precautions for a client who has had a tonic-clonic seizure. Which of the following interventions should the nurse include in the plan of care? Insert an IV saline lock. A nurse is making an Initial postpartum home visit. Which of the following client statements should the nurse Identify as a manifestation of Increased risk for child abuse? "I think the baby should be sleeping through the night by now." A nurse is observing a newly licensed nurse who is administering total parenteral nutrition (TPN) to a client. Which of the following actions by the newly licensed nurse indicates a need for the nurse to intervene? Gradually increases the TPN infusion rate each hour until the prescribed rate is achieved Use the TPN tubing for antibiotic A nurse is obtaining care for a clieture of a newborn. Which of the following sites should the nurse use? Place the client's head of bed flat. A nurse is obtaining the temperature of a newborn. Which of the following sites should the nurse use? Axillary A nurse is performing a neurological examination on a client as part of a complete physical assessment. The nurse should identify that cranial nerve XI is intact when the client performs which of the following actions? Shrugs his shoulders A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the client's body should the nurse observe to assess for jaundice? Sclera A nurse is planning a community health program about Parkinson's disease. Which of the following interventions should the nurse Include as a tertiary prevention strategy? Provide daily exercise classes to improve ambulation for clients who have Parkinson's disease. A nurse is planning care for a client who is returning to the unit following open gastric bypass surgery. Which of the following interventions should the nurse include in the client's plan of care? Measure and compare abdominal girth daily. A nurse is planning care for a client who is scheduled to have a paracentesis. Which of the following actions should the nurse include in the plan of care? Instruct the client to empty her bladder prior to the procedure. A nurse is planning care for a client who is scheduled to receive a peripherally inserted central catheter in the arm. Which of the following interventions is appropriate for the nurse to include in the plan of care? Measure the arm circumference above the insertion site daily A nurse is planning care for a client who is scheduled to receive a transfusion of packed RBCs. Which of the following actions should the nurse plan to take? Use a solution of 0.9% sodium chloride to flush the transfusion tubing. A nurse is planning care for a client who is to receive alteplase recombinant for a thrombus in the coronary artery. Which of the following actions should the nurse include in the plan of care? Observe for bruising of the skin. A nurse is planning care for a client who sustained a major burn over 20% of the body. Which of the following interventions should the nurse include to support the client's nutritional requirements? Keep a calorie count for foods and beverages. A nurse is planning care for a group of clients and is working with one licensed practical nurse (LPN) and one assistive personnel (AP). Which of the following actions should the nurse take first to manage her time effectively? Determine goals of the day. A nurse is planning care for a preschool-age child who is in the acute phase of Kawasaki disease. Which of the following interventions should the nurse include in the plan of care? Monitor the child's cardiac status. A nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis. Which of the following actions should the nurse include in the plan of care? Administer analgesics on a scheduled basis for the first 24 hr. A nurse is planning care for a toddler who has epiglottitis. Which of the following interventions should the nurse include? Initiate droplet precautions. A nurse is planning teaching for a client and their family about home oxygen therapy. Which of the following information should the nurse plan to include in the teaching? Avoid using nail polish remover around the client. A nurse is planning teaching for a client who has a newly implanted implantable cardioverter/defibrillator. Which of the following information should the nurse include? Wear loose-fitting clothing. A nurse is planning to administer vancomycin IV to a client. Which of the following actions should the nurse take to reduce the risk of an adverse reaction to the vancomycin? Give the dose over 60 min. A nurse is planning to delegate the fasting blood glucose testing for a client who has diabetes mellitus to an assistive personnel (AP). Which of the following actions should the nurse take? Determine if the AP has the skills to perform the test. A nurse is positioning a client for a cesarean birth. To prevent a compromise in placental blood flow during the intraoperative period, which of the following actions should the nurse take? Place a wedge under one of the client's hips. A nurse is preparing a client for transfer to a long-term rehabilitation facility following a below-knee amputation of the right leg. Which of the following actions should the nurse take to protect the client's confidentiality? Provide a verbal report of the client's condition to the paramedic performing the transfer. A nurse is preparing a client to undergo a cardiac catheterization. Which of the following tasks should the nurse perform prior to the procedure? Obtain a CBC with differential. A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching as an example of malpractice? Adminster potassium IV Bolus A nurse is preparing to administer an IV medication to a client and accidently punctures the IV bag, causing the medication to leak on the counter. Which of the following medications requires the nurse to follow facility procedures in the safe handling of a biohazardous material spill? Doxorubicin hydrochloride A nurse is preparing to administer dopamine hydrochloride 4 mcg/kg/min via continuous infusion. Available is dopamine hydrochloride in a solution of 800 mg in a 250 mL bag. The client weighs 80 kg. The nurse should set the IV infusion to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies.) 6 mL/hr. A nurse is preparing to administer levothyroxine 50 micrograms to a client. Available is levothyroxine 0.025 mg/tablet. How many tablets should the nurse administer per dose? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) 2 A nurse is preparing to administer PRN pain medication to a client who has cholelithiasis and is experiencing moderate abdominal pain. Which of the following medications should the nurse plan to administer? Acetaminophen A nurse is preparing to administer the first dose of cefazolin via intermittent Order and refuses to take their medication. Which of the following nurse take first? Review the client's allergy history. A nurse is preparing to administer three medications to a client who is receiving continuous enteral feeding through an NG tube. Which of the following actions is appropriate for the nurse to take? Use a syringe to allow the medications to flow by gravity. A nurse is preparing to administer three medications to a client who is receiving continuous enteral feeding through an NG tube. Which of the following actions is appropriate for the nurse to take? Use a syringe to allow the medications to flow by gravity. A nurse is preparing to admit a 6-year-old with varicella to the pediatric unit. Which of the following actions should the nurse take? Assign the child to a negative air pressure room. A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse take? Wear gloves to apply the patch to the client's skin. A nurse is preparing to catheterize a toddler for a urine culture. Which of the following is an appropriate action for the nurse to take? Don sterile gloves prior to the procedure. A nurse is preparing to collect a sputum specimen from a client. Which of the following actions should the nurse take? Obtain the specimen immediately upon the client waking up. A nurse is preparing to initiate intravenous fluids via infusion pump for a client. Which of the following actions should the nurse take? Check the expiration date on the safety inspection sticker of the pump. A nurse is preparing to insert an IV catheter for a client. Which of the following actions should the nurse plan to take? Choose a vein that is palpable and straight. A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field? Place the cap from the solution sterile side up on a clean surface. A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at a peripheral IV site. Which of the following actions should the nurse plan to take? Place a warm, moist compress on the site. A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first? A client who is ambulatory and receiving oxygen. A nurse is providing care for a client following a thoracentesis. If the client develops a pneumothorax, which of the following assessment findings should the nurse expect? Pain on inhalation A nurse is providing care for a client who experienced a myocardial infarction prior to a cardiac arrest. Which of the following laboratory tests will identify early injury to the cardiac muscle? Troponin T test A nurse is providing care for a client who has esophageal cancer and has received radiation therapy. Which of the following findings should the nurse identify as the priority? Dysphagia A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include? Consume foods high in bran fiber. A nurse is providing discharge instructions to a client who has a new prescription for haloperidol. Which of the following adverse effects should the nurse instruct the client to report to the provider? Shuffling gait A nurse is providing discharge teaching about car seat safety to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? "I will position my baby at a 45-degree angle in the car seat." A nurse is providing discharge teaching for a client who has a new implantable cardioverter defibrillator (ICD). Which of the following client statements demonstrates understanding of the teaching?"I will wear loose clothing over my ICD." A nurse is providing discharge teaching for the guardian of a school-age child following a cardiac catheterization. Which of the following instructions should the nurse include in the teaching? "You should remove your child's pressure dressing tomorrow." A nurse is providing discharge teaching to a client following a total gastrectomy. The nurse should instruct the client about which of the following medications? Vitamin B12 A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following Instructions should the nurse include in the teaching? Eat 1 g/kg of protein per day. A nurse is providing discharge teaching to a client who is postoperative following surgery for carpal tunnel syndrome. Which of the following statements by the client indicates an understanding of the teaching? "I will need to keep my hand elevated above my heart for several days." I should not use my affect hand for 4 to 6 weeks A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina. Which of the following statements by the client indicates an understanding of the teaching? I can lift objects that are less than 10 pounds A nurse is providing discharge teaching to a new parent about breastfeeding her infant. Which of the following statements should the nurse make? "Offer your infant the breast when he shows signs of hunger." A nurse is providing discharge teaching to the partner of a client who has a tracheostomy. Which of the following information should the nurse include in the teaching? How to operate the portable suction machine. A nurse is providing Information for a client who has a new prescription for simvastatin. For which of the following should the nurse Instruct the client to monitor and report to the provider? Muscle weakness A nurse is providing preoperative teaching to a client about promoting circulation during the postoperative period. Which of the following instructions should the nurse include? Participate in range-of-motion exercises A nurse is providing preoperative teaching to a client about the administration of morphine via a PCA pump. Which of the following statements by the client indicates an understanding of the teaching? "I will receive a limited amount of pain medication when I press the button." A nurse is providing preoperative teaching to an older adult client who is scheduled for surgery. Which of the following actions should the nurse take to promote learning? Connect new information with the client's past experiences. A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching? "Have your child drink a small glass of water after swallowing the medication. A nurse is providing teaching about home safety to the adult child of an older adult client who is postoperative following knee replacement surgery. Which of the following instructions should the nurse include? Ensure that area rugs have rubber backs. . A nurse is providing teaching about nonpharmacological pain management to a client who has osteoarthritis. Which of the following Instructions should the nurse include in the teaching? Take a hot shower every day. A nurse is providing teaching about the use of crutches using a three-point gait to a client who has a tibia fracture. Which of the following actions by the client indicates an understanding of the teaching? Positioning both hands on the grips with his elbows slightly flexed A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include? Excessive sweating A nurse is providing teaching to a client who diabetes metillites about the glycoscted hemogobin blood test. Which of the following statement by the client indicate the understanding? I will use this test to monitor how well I control my blood glucose levels A nurse is providing teaching to a client who has a new diagnosis of multiple sclerosis. Which of the following statements should the nurse make? "Use a cane when walking to maintain your balance." A nurse is providing teaching to a client who has thrombocytopenia following chemotherapy. Which of the following statements Indicates an understanding of the teaching? "I will wipe my nose instead of blowing it."v A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching? Swelling of the face A nurse is providing teaching to a client who is to begin external radiation therapy for cancer. Which of the following information should the nurse include? "You might experience altered taste sensations." A nurse is providing teaching to a client who is undergoing radiation therapy and has stomatitis. Which of the following responses by the client indicates an understanding of the teaching? "I should use a soft-bristle toothbrush to clean my teeth after meals." A nurse is providing teaching to a parent of a child who has varicella. Which of the following statements should the nurse include in the teaching? "Your child can return to school once the lesions have crusted over." A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include? Eat a light snack before bedtime. A nurse is providing teaching to an older adult client who has a seizure disorder and a new prescription for phenytoin. Which of the following instructions should the nurse include? "Plan to take this medication with food." A nurse is providing teaching to family members of a client who has dementia. Which of the following Instructions should the nurse include in the teaching? Establish a toileting schedule for the client. A nurse is providing teaching to the parents of a newborn about newborn genetic screening. Which of the following statements should the nurse include in the teaching? "This test should be performed after your baby is 24 hours old." A nurse is reading a tuberculin skin test for a client who received a purified protein derivative test 72 hr ago. Which of the following findings indicates a positive test? An induration measuring 10 mm A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first? A client who has a hip fracture and a new onset of tachypnea. A nurse is reporting a client laboratory to the provider to obtain a prescription for the client daily warfarin. Which of the following laboratory test should the nurse plan to report to obtain the prescription for warfarin? INR A nurse is reviewing home recommendations with a client who is postoperative following knee surgery. Which of the following recommendations should the nurse make?Ensure that all area rugs are rubber-backed. A nurse is reviewing laboratory data from a client who has chronic kidney disease. Which of the following findings should the nurse expect? Increase creatinine A nurse is reviewing the medical history of a client who asks about the use of warfarin. The nurse should identify which of the following findings as a contraindication for the administration of this medication? Recent eye surgery A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings requires follow-up care? A client who is scheduled for a colonoscopy and is taking sodium phosphate. A client who TB skin test place 48 hr and have a induration A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution? Remove the cap and place it sterile-side up on a clean surface. A nurse is speaking with the caregiver of a client who has Alzheimer's disease. The caregiver states, "Providing constant care is very stressful and is affecting all areas of my life." Which of the following actions should the nurse take? Assist the caregiver to arrange for a daycare program for the client. A nurse is suctioning the airway of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following findings should the nurse identify as an indication that the suctioning has been effective? Decreased peak inspiratory pressure Prescence of productive cough A nurse is teaching a client about a variety of stress management techniques. Which of the following instructions by the nurse is appropriate? "Tighten your muscles before relaxing them when using muscle relaxation techniques." A nurse is teaching a client about advance directives. Which of the following statements by the client indicates an understanding of the teaching? "A living will is a document that includes my wishes about health care decisions." A nurse is teaching a client about condom use. Which of the following client statements should the nurse Identify as an understanding of the teaching? "I can store the condoms in the drawer of my nightstand." A nurse is teaching a client about family planning using the basal body temperature method. Which of the following Instructions should the nurse include in the teaching? "Take your temperature immediately after waking and before getting out of bed." A nurse is teaching a client about family planning using the basal body temperature method. Which of the following instructions should the nurse include in the teaching? Take your temperature immediately after waking and before getting out of bed." A nurse is teaching a client who has a new prescription for an MAOI. Which of the following foods is contraindicated with this medication? Cheese A nurse is teaching a client who has chronic pain about avoiding constipation from opioid medications. Which of the following information should the nurse include in the teaching? Increased exercise A nurse is teaching a client who is pregnant and has genital herpes simplex virus (HSV). Which of the following statements should the nurse include in the teaching? "You will need to have a cesarean birth if there are any visible lesions." A nurse is teaching a client who is trying to conceive. Which adolescent client. The nurse should expect the adolescent to be in which of the a neural tube defect? Folate A nurse is teaching a client who plans to begin following vegan dietary guidelines. Which of the following information should the nurse include? Choose foods high in vitamin B12 A nurse is teaching a group of school-age children about healthy snack options. Which of the following snacks should the nurse include? Air-popped popcorn A nurse is teaching a new parent about breastfeeding her 2-week-old infant. Which of the following statements by the parent indicates an understanding of the teaching? “The more my baby is at the breast sucking, the more milk I will produce.”. A nurse is teaching a newly licensed nurse about caring for clients in the emergency department. Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly? Tell the client, "You seem to be very upset." A nurse is teaching a parent of a school-age child who is to begin a daily dose of methylphenidate. Which of the following should the nurse include in the teaching? "You should administer the medication before breakfast." A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching? "I can visit my nephew who has chickenpox 5 days after the sores have crusted." A nurse is teaching about preventative measures to a female client who has chronic urinary tract infections. Which of the following instructions should the nurse include in the teaching? "Drink 2 liters of water per day." A nurse is teaching dietary guidelines to a client who has celiac disease. Which of the following food choices is appropriate for this client? Potato pancakes A nurse is teaching the parents of a child who has a new onset of seizures and is to undergo an electroencephalogram (EEG) about the procedure. Which of the following instructions should the nurse include in teaching?" Ensure the child's hair is clean and without conditioner before the procedure." A nurse is teaching the parents of a school-age child who is newly diagnosed with Juvenile Idiopathic arthritis. Which of the following Interventions should the nurse Include in the teaching? Have the child take a tub bath each morning Encourage the child to take naps during the day A nurse is updating the plan of care for a client who has amyotrophic lateral sclerosis with dysphagia. Which of the following interprofessional team members should the nurse identify as the priority to consult? Speech-language pathologist A nurse is verifying a record of Informed consent for a client who is scheduled for surgery. Which of the following actions should the nurse take? Confirm the client's signature is authentic. A nurse isproviding discharge teaching to a client who has cancer and a prescription for a fentanyl 25 mcg/n transdermal patch. Which of the following instruction should the nurse include in the teaching? Avoid hot tub while wearing the patch A nurse manager is addressing reports of conflict within a nursing unit. The nurse should identify which of the following situations as an example of interpersonal conflict? A nurse experiences insulting comments directed at them by another nurse A nurse manager is planning a staff in-service to address advocacy in client care. The nurse should promote which of the following practices during the in- service? (Select all that apply.) Promoting health care access Encouraging clients to seek further information from the provider Addressing client needs when providing resources A nurse manager is preparing to meet with a group of staff nurses who are experiencing conflict. Which of the following mediation strategies should the nurse manager plan to implement to resolve the conflict? Facilitate discussion until all parties agree. A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include? Document the client's condition every 15 min. A nurse manager on an interprofessional team is creating a disaster plan. The nurse should include in the plan that which of the following actions is the responsibility of the unit nurse during a disaster? Recommend to the provider a list of clients for early discharge. A nurse observes a client on the psychiatric unit muttering and standing near a window. The client states, "The voices are telling me to jump." Which of the following is an appropriate response by the nurse? "I understand the voices are frightening you, but I do not hear any voices." A nurse on a medical-surgical unit is planning care for assigned clients. Which of the following actions should the nurse plan to take to demonstrate effective time management? Complete activities for one client before moving to the next client. A nurse on a mental health unit is teaching a newly licensed nurse about the use of mechanical restraints. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? "I should visually monitor the client continuously when in mechanical restraints. A nurse on a telemetry unit is assessing a client who is receiving continuous cardiac monitoring. The client's heart rate is 69/min and the PR interval is 0.24 seconds. The nurse should interpret this finding as which of the following cardiac rhythms? First-degree AV block A nurss caring for a client with implanted venous device. How the nurse will access it? Noncoring needle A school nurse is performing scoliosis screenings. The nurse should recognize which of the following clinical manifestations as an Indication of scoliosis? Uneven shoulder and pelvic heights A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include? "This type of seizure can be mistaken for daydreaming." An occupational health nurse is providing teaching to a group of factory workers about proper lifting techniques. Which of the following statements should the nurse make? "Tighten abdominal muscles to improve balance." Endometritis is temperature chills, foul smelling lochia Mastitis is tender breast, temperature, chills A nurse working in the emergency department (ED) is admitting a client. Day 1, 1030: No known allergies COPD Hypertension Hypothyroidism Dermatitis Type 2 diabetes mellitus Smokes 1 pack of cigarettes per day Nurse notes Day 1, 1030: Client reports feeling short of breath, productive cough with yellow sputum, and pleuritic chest pain. Runny nose, myalgia along with headache for the past 3 days. "I woke up feeling worse and started to feel nauseated and couldn't eat my breakfast, so I thought I should come in." Client reports pleuritic chest pain as 6 on a scale of 0 to 10. Skin is moist. Lungs sounds are diminished in lower lobes with crackles. Bowel sounds are normoactive in all quadrants. Last bowel movement this morning. Reports no difficulty urinating. Reports nausea with no vomiting. Able to move all extremities. Pedal pulses present +2. Client is oriented to person, place, and time. Vital signs Day 1, 1030: Temperature 39.4° C (102.9° F) Pulse rate 112/min Respiratory rate 24/min Blood pressure 168/90 mm Hg Oxygen saturation 88% on room air Day 1, 1900: Temperature 38.3° C (100.9° F) Pulse rate 102/min Respiratory rate 24/min Diagnostic test Day 1, 1030: 12-lead electrocardiogram: sinus tachycardia Chest x-ray: right lower lobe pneumonia Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again. Nurses' Notes Day 1, 1030: Client reports feeling short of breath, productive cough with yellow sputum, and pleuritic chest pain. Runny nose, myalgia along with headache for the past 3 days. "I woke up feeling worse and started to feel nauseated and couldn't eat my breakfast, so I thought I should come in." Client reports pleuritic chest pain as 6 on a scale of 0 to 10. Skin is moist. Lungs sounds are diminished in lower lobes with crackles. Bowel sounds are normoactive in all quadrants. Last bowel movement this morning. Reports no difficulty urinating. Reports nausea with no vomiting. Able to move all extremities. Pedal pulses present +2. Client is oriented to person, place, and time. For each potential provider's prescription, click to specify if the prescription is anticipated or contraindicated for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column. Anticipated Contraindicated Obtain sputum culture X Increase supplemental oxygen to keep oxygen saturation greater than or equal to 95% X Administer regular insulin X Place client on 1,500 mL fluid restriction C The nurse is preparing the client for a thoracentesis. Select the 4 actions that the nurse should take. A Place the client in an upright position leaning over a bedside table. B Inform the client they will be sedated for the procedure. C Obtain informed consent from the client. D Explain that a needle will be inserted in the pleural space to withdraw fluid. E Administer a cough suppressant to the client prior to the procedure. F Inform the client that they will need to fast 4 hr prior to the procedure Day 1, 1030: No known allergies COPD Hypertension Hypothyroidism Dermatitis Type 2 diabetes mellitus Smokes 1 pack of cigarettes per day Day 1, 1030: Client reports feeling short of breath, productive cough with yellow sputum, and pleuritic chest pain. Runny nose, myalgia along with headache for the past 3 days. "I woke up feeling worse and started to feel nauseated and couldn't eat my breakfast, so I thought I should come in." Client reports pleuritic chest pain as 6 on a scale of 0 to 10. Skin is moist. Lungs sounds are diminished in lower lobes with crackles. Bowel sounds are normoactive in all quadrants. Last bowel movement this morning. Reports no difficulty urinating. Reports nausea with no vomiting. Able to move all extremities. Pedal pulses present +2. Client is oriented to person, place, and time. Day 1, 1900: Client still short of breath. Lung sounds are diminished in posterior lobes along with crackles. Cough productive with yellow sputum. Encouraged to cough and deep breathe along with use of incentive spirometer while awake. Client reports thirst. IV fluids infusing and receiving IV antibiotics. Contacted provider. Day 4, 1030: Client states, "It is easier to breathe and I'm not as short of breath." Lung sounds still diminished with crackles. No wheezes detected. Client is on oxygen at 1 U/min via nasal cannula and oxygen saturation is 92%. Client reports pleuritic chest pain as 3 on a scale of 0 to 10. Cough is productive and sputum is yellow. Drinking 2 L per day. Voided 200 ml of clear yellow urine. Day 1, 1030: Temperature 39.4° C (102.9° F) Pulse rate 112/min Respiratory rate 24/min Blood pressure 168/90 mm Hg Oxygen saturation 88% on room air Day 1, 1900: Temperature 38.3° C (100.9° F) Pulse rate 102/min Respiratory rate 24/min Day 1, 1030: A nurse is caring for a toddler admitted to the hospital. Nurses' Notes 1200: Parent reports with child who has had diarrhea and decreased appetite for 3 days. Toddler alert, uncooperative but is consoled by the parent. Weight 12.72 kg (28 lb). Oral mucosa pink, slightly moist. Heart rate regular without murmur. Respirations unlabored with clear breath sounds. Abdomen soft, no masses, hyperactive bowel sounds. Liquid stool in diaper. Diaper area with erythema noted. Capillary refill 2 seconds. IV started and infusing at 45 mL/hr. 1400: Parent reports child cried themselves to sleep. Reports no tears. 1600: Child continues to sleep. IV site intact and patent. Awakens briefly with vital signs, vomits x 1, and is lethargic. Capillary refill 4 seconds. Extremities cool. Body Systems Findings Respiratory Respiratory rate 26/min Heart rate 112/min Cardiovascular Gastrointestinal Capillary refill 4 seconds Hyperactive bowel sounds Diaper area reddened with erythema noted Integumentary Extremities cool Reports no tears Neurologic Lethargic