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A nurse is caring for a client. Which of the following findings require immediate follow-up? Select all that apply. Vital Signs 1600 Temperature 99.7•F Blood pressure 110/58 mmHg Heart rate 72/min Respiratory rate 18/min Pulse oximetry 98% on room air 1630 Temperature 99.5•F Blood pressure 78/52 mmHg Heart rate 112/min Respiratory rate 26/min Pulse oximetry 92% on room air Nurse’s Notes 1600 Antibiotic administered as prescribed. Bilateral breath sounds clear and present throughout. 1630 Client reports itching on the chest and has a rash over the chest and trunk.Client states they are having difficulty swallowing and feel as if there is a lump in their throat. Bilateral breath sounds with scattered wheezing heart throughout.

The nurse is caring for client 82 years of age who is struggling to adapt to hearing loss as he ages. The nurse performs which of the following interventions to assist the client in adapting to this sensory deficit? Choose all that apply.

The nurse is calculating intake and output (I & O) for a patient. On the I&O record, the following information is noted: milk 140 mL at breakfast, voided 240 mL after breakfast, 120 mL of coffee at 1000, and urinated 300 mL at 1100. Which amount will the nurse document for the total urine output?

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?