A post-surgical client has developed a temperature of 101 F, 24 hours after surgery.  The nurse assesses the client and has auscultated scattered crackles and rhonchi throughout the chest.  The nursing diagnosis is ineffective airway clearance.  After performing nursing interventions, which outcome/evaluation would indicate a therapeutic response to treatment? 

A nurse is caring for a client who is terminally ill. Which of the following statements would the nurse identify as a therapeutic response from a family member?

 A client who has pneumonia has had a fever for three days.  What characteristics would the nurse anticipate related to the clients urinary output?   

The nurse is inserting an oropharyngeal airway and the client vomits when it is inserted.  What is the first action that should be taken by the nurse related to the occurrence?

The client has been complaining of shortness of breath for two weeks and has been admitted with the nursing diagnosis of impaired gas exchange. Which diagnostic test result would provide support/evidence for this nursing diagnosis? 

Which nursing diagnosis would be appropriate for a client who has a retention catheter and the drainage bag is found lying on the floor? 

What assessment findings or client conditions would indicate the need for suctioning? Select all that apply.

 What documentation would be most appropriate when recording the results of the administration of a soap suds enema (SSE) to the client? 

A client is complaining of pain when the balloon of an indwelling catheter is inflated. What should the nurse do next?

The nurse is caring for a client who has an acute infection.  Which assessment findings indicate the cardinal signs of acute infection?  Select all that apply