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While assessing a patient, the nurse notes that the pulse is easily detected, feels strong, and regular and has even beats with moderate force. How should the nurse document this pulse?

A patient accidentally receives an entire liter of IV fluid over 3 hours. Which should the nurse expect when assessing this patient’s pulse?

In which situation should a nurse assess vital signs instead of delegating it to unlicensed assistive personnel (UAP)? Select all that apply.

A nurse applies wrist restraints to a patient. Which actions indicate appropriate technique? Select all that apply.

A nurse is assessing a client’s body temperature. The nurse could obtain an accurate body temperature at the oral site for a client:

A nurse is caring for a client with orthostatic hypotension. Which nursing interventions are appropriate to decrease the risk of falls? Select all that apply.

When assessing an adult client’s pulse at 125 beats/min, which step would the nurse take first to determine intervention?

An appropriate environmental nursing intervention for a patient with respiratory congestion is to:

The West Monroe papermill has experienced an explosion and chemical fire. Fifty workers have been transported to the ER. As the triage nurse, you must appropriately triage the following patients based on the standard green, yellow, red or black triaging system. 61 year old female Has blood in nose, mouth, and ears. She is not breathing Faint, thready pulse Unresponsive 44 year old male c/o abdominal tenderness Has a minor abdominal injury with shrapnel Currently wandering around looking for spouse who is also an employee of the company is Awake & Oriented  RR 24 Strong radial pulse 32 year old male Right upper extremity arterial bleed and second degree burns to 20% of the body Awake and oriented  Reacts to pain RR 38 States “I’m so thirsty!”

Each resident admitted must have a fall risk assessment performed so that appropriate actions to prevent falls can be included in the nursing care plan. The items are considered when doing a fall risk assessment on a newly admitted resident include: (Select all that apply.)