The nurse is caring for a patient who has a continent ileostomy. Which intervention should the nurse add to the plan of care?

A client tells the nurse that he takes laxatives every day but is still constipated. The nurse’s response is based on:

A client in a physician’s office has a single blood pressure (BP) reading of 150/92. Should the client be told he has hypertension?

A nurse is caring for an older adult client in the emergency department. Which of the following findings require immediate follow-up? Select all that apply. Current vital signs: Temperature 39.3° C (102.8° F) Heart rate 93/min Respiratory rate 24/min Blood pressure 88/58 mm Hg Oxygen saturation 95% on room air Medical History: Older adult client, lives with family. Family states the client is normally alert and oriented but began to display confusion over the last 6 hr and has a new onset of incontinence. Client reports dizziness and constant low back and flank pain. Urinalysis: Appearance: cloudy                                                 Color: dark amber                                                    Odor: foul                                                                  pH: 8.0                                                                      Protein: 6.5 mg/dL                                                  Specific gravity: 1.035                                            Leukocyte esterase: positive                                 Nitrates: present                                                   Ketones: none                                                         Glucose: none                                                         White blood cells: 8                                            Red blood cells:  1                                               

The nurse is providing care for a pediatric client on night shift. At 0400, the nurse notes that the child has a high fever but does not have an order for an antipyretic. What nursing action represents a good example of teamwork and collaboration ? The nurse:

The nurse is developing a plan of care for a client with anxiety. Which are appropriate nursing interventions the nurse can use for assisting the client in reducing anxiety? Select all that apply.

Which of the following questions would be helpful in eliciting data about the effects of stress during a health history?

A nurse assesses a terminally ill patient with a DNR order, with findings of decreased blood pressure, urinary and bowel incontinence, loss of reflexes, agitation and Cheyne-Stokes respirations. Based on these findings, the nurse recognizes which of the following?

A client’s PaCO 2 is abnormally low on an ABG report, while the pH is above 7.45 and the HCO3 is normal. Which of is the most likely cause?

What statement or question is useful for a nurse if a client asks the nurse to pray with him or her?