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The nurse is caring for a patient with uncontrolled hypertension. His blood pressure has remained controlled for the nurse’s shift. At two-hour intervals the blood pressure was checked by the nurse and found to be essentially the same. The nurse, although taking the blood pressure as directed, forgets to write down the number. During the next shift, the patient has a stroke. Years later, the patient files a lawsuit blaming the hospital for his stroke. The nurse who was caring for the patient when his blood pressure was stable cannot recall the exact blood pressure she obtained, but remembers it was normal. Will this recollection suffice in court and why?

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client’s pulse. Which of the following actions should the nurse take?

A nurse is caring for a toddler who is having an acute asthmatic attack with copious mucus and difficulty breathing. The child’s skin is cyanotic, respirations are labored and rapid, and pulse is rapid. What nursing diagnosis would have priority for care of this child?

A nurse is preparing a presentation at a community center about complementary and alternative therapies. Which of the following therapies should the nurse describe as the use of an electronic monitoring device  (ie heart rate monitor) to help clients learn to control physical response to stress?

A nurse is providing care for a client who is 2 days postoperative following abdominal surgery and is about to progress from a clear liquid diet to full liquids. Which of the following items should the nurse tell the client he may now request to have on his meal tray?

In order to prevent the possibility of venous stasis, a nurse is teaching a client who had abdominal surgery how to perform leg exercises. Which of the client’s following statements indicates a sound understanding of leg exercises?

A nurse is teaching a client who has a history of falls about home safety. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. The client is reporting discomfort and a feeling of bloating. Which of the following actions is the nurse’s priority?

A nurse is performing patient education regarding CPAP explains that the rationale for using CPAP to treat sleep apnea is to provide:

The nurse is assessing a 16-year-old female client’s knowledge of sexuality. Which of her statements indicates that she requires further teaching?