A nurse in a hospital is conducting a physical assessment with a partly undressed patient. What action by the nurse is most appropriate?

The student nurse performs orthostatic blood pressure readings during morning assessment. The results are: lying 146/78 mm Hg, sitting 128/68, and standing 110/62 mm Hg. What action by the nurse is best?

The nurse has identified several problems for a patient scheduled for a bone marrow transplant. By formulation of nursing diagnoses, the nurse:

The nurse writes an expected outcome statement in measurable terms. An example is: 

A patient requires frequent blood pressure (B/P) measurements after being admitted with a gunshot wound. The registered nurse (RN) is delegating the task of collecting B/P measurements to a licensed practical nurse (LPN). When delegating, the RN  knows which statement to be true?

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?