The nurse responds to a patient’s call light. Upon entering the room, the nurse sees that the patient is lying on the floor, with bed linens around the legs. What is the most appropriate documentation for this incident?

A 71-year-old client is hospitalized with a cerebral vascular accident (stroke). She becomes disoriented at times and tries to get out of bed, but cannot ambulate without help. What is the most appropriate safety measure?

How can a nurse prioritize clients care? 

The nurse identifies that a patient’s pressure ulcer has skin loss involving the epidermis and dermis. The nurse documents that the patient’s pressure ulcer is: 

A client is brought to the emergency department after being involved in a motor vehicle crash. Although the client is conscious, her condition is critical and will require emergency surgery. The client does not speak English. What is the best action of the staff?

The nurse is caring for a patient post-operatively following the creation of a colostomy. Which nursing diagnosis should the nurse include in the plan of care?

A hospitalized patient complains of bilateral leg pain and asks the nurse to massage her legs. One calf is noticeably larger than the other and is warm and slightly reddened. What action by the nurse is best?

The nurse has just completed an admission interview with a new patient. Which response by the nurse is an example of a remark that may be used during the closing phase of the interview?

An 85-year-old patient in a nursing home tells a nurse, “Because the doctor was so insistent, I signed the papers for the research study. I was afraid he would not continue taking care of me. Which patient’s right is being violated?

Before the clinical experience begins, the student must be aware of the client’s pertinent history, daily treatments, diagnostic procedures, medications, allergies, problems, and other information in order to provide the most appropriate care during the shift. Where would the student research this information?