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The nurse is assessing a client who is in end stage liver failure with portal hypertension due to an obstruction in the portal vein. Which independent nursing intervention should the nurse include in the plan of care?

Which of the assessment data indicates the client is high risk for pressure injury development? SELECT ALL THAT APPLY. The nurse is developing a plan of care for an 86-year-old client who was admitted one day ago, for left hip arthroplasty (LTHR). On admission the labs hemoglobin 16.2g/dL hematocrit 44 %; Bun 12mg/dL, creatinine 0.7 mg/dL and WBC 6,400/uL. Overnight the client experienced two episodes of incontinence. This morning the client is experiencing increase pain with activity. Oxycodone was administered with some relief. 

A client with a history of peptic ulcer disease arrives to the clinic complaining of epigastric pain. Which question is MOST appropriate to ask the client who is being evaluated for exacerbation of peptic ulcer disease?

A client comes into the clinic reporting sudden onset of low back pain. During the health history, the client states that the pain began yesterday after building a shed. The client is diagnosed with a pulled muscle. The nurse is providing education to the client on the management of lower back pain. Which key concept would the nurse include to promote healing and prevent any further strain to the lower back?           

The nurse is caring for a client with a hiatal hernia. The nurse comes into the room after dinner to administer an antacid. The nurse finds an empty dinner tray, can of soda and a bag of chips at the bedside. The client is lying flat in bed with their legs elevated watching TV. The nurse reinforces the importance of which intervention regarding the management of hiatal hernia at this time? 

The nurse is caring for a client following foot surgery. The client was placed under general anesthesia and will be non-weight bearing for 2 weeks. Which intervention is MOST important for the nurse to include in the immediate post-operative period?

The nurse is preparing the client diagnosed with laryngeal cancer for a radical neck dissection in the morning. Which intervention should the nurse PRIOITIZE when preparing this client for surgery? 

The nurse is caring for a client who is admitted for the treatment of advanced cirrhosis. Which assessment should the nurse PRIORITIZE in the client’s plan of care?

The nurse is providing free cancer screening at the local Health Department. Which complaint is significant for the nurse to assess in a 30-year-old male client who uses oral tobacco?

The nurse is assessing the stoma of a client who had an ostomy placed on left abdomen six (6) days ago. Which assessment finding(s) necessitates further evaluation of the stoma. SELECT ALL THAT APPLY.