A nurse is providing discharge teaching to a 72-year-old cli…
A nurse is providing discharge teaching to a 72-year-old client who received bilateral hearing aids 3 days ago for moderate sensorineural hearing loss. The client reports frustration because “everything sounds too loud and confusing.” The client has been wearing the devices continuously since fitting. Vital signs: BP 134/80 mmHg, HR 74 bpm, RR 16 breaths/min. Which instruction is most appropriate?
Read DetailsA nurse witnesses a 45-year-old client sign an informed cons…
A nurse witnesses a 45-year-old client sign an informed consent form for laparoscopic cholecystectomy scheduled in 2 hours. The client received lorazepam 2 mg PO 15 minutes ago for anxiety and now appears drowsy. The surgeon has left the unit. The client asks, “What are the risks of this surgery again?” Which action should the nurse take?
Read DetailsAn ED nurse is caring for a 29-year-old client who presents…
An ED nurse is caring for a 29-year-old client who presents 6 hours after a sexual assault. History: no significant medical history, last menstrual period 2 weeks ago. Current findings: alert but withdrawn, multiple bruises on arms and thighs, reports vaginal pain. Vital signs: BP 138/86 mm Hg, HR 98 bpm, RR 20 breaths/min, SpO2 98% on room air. The client states, “I just want to shower and go home.” Which response by the nurse is most appropriate?
Read DetailsA nurse is completing a visual assessment on a 62-year-old c…
A nurse is completing a visual assessment on a 62-year-old client with a 15-year history of type 2 diabetes and hypertension. The client reports “seeing floaters and flashing lights” for 2 days. Visual acuity: right eye 20/40, left eye 20/100. Vital signs: BP 168/96 mmHg, HR 84 bpm, RR 18 breaths/min, glucose 246 mg/dL. Which assessment finding requires the most immediate follow-up?
Read DetailsAn ED nurse is caring for a 19-year-old client brought in by…
An ED nurse is caring for a 19-year-old client brought in by EMS after ingesting an unknown quantity of acetaminophen 3 hours ago. History: depression, previous suicide attempt. Current findings: alert and oriented, reports nausea, denies abdominal pain. Vital signs: BP 118/72 mm Hg, HR 88 bpm, RR 16 breaths/min, SpO2 98% on room air. Which interventions should the nurse anticipate? (Select all that apply.)
Read DetailsAn ED nurse is caring for a 42-year-old client found unrespo…
An ED nurse is caring for a 42-year-old client found unresponsive outdoors during a winter storm. History: unknown, found lying in snow for estimated 2 hours. Current findings: difficult to arouse, skin cold and pale, shivering absent, speech slurred. Vital signs: BP 88/54 mm Hg, HR 48 bpm, RR 8 breaths/min, core temperature 29.4°C (85°F), SpO2 88% on room air. Which action should the nurse anticipate first?
Read DetailsA nurse develops a care plan for a client in the rehabilitat…
A nurse develops a care plan for a client in the rehabilitation phase, 8 weeks after 40% TBSA burns: grafted areas on both arms appear pink and flat, client reports intense itching, and new scar tissue limits elbow extension by 15 degrees. Which interventions are appropriate? Select all that apply.
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