The nurse is performing an admission assessment on a client admitted with a diagnosis of fever of unknown origin.  Which nursing action demonstrates competence under the Nurse Practice Act?

The nurse is teaching a new graduate nurse about documentation in the electronic health record. Which statement below should the new graduate nurse identify as accurate and appropriate for the electronic health record? 

A client was admitted with a myocardial infarction 3 days ago, and is now stable.  Which activity should not be delegated to the unlicensed assistive personnel?    

The nurse is caring for an adult client with a diagnosis of obsessive-compulsive disorder who was admitted to the inpatient psychiatric unit. The nurse observes that the client has been excessively washing their hands and face. What intervention by the nurse is most appropriate to address this behavior?   

The nurse is providing preoperative teaching about pain management techniques to a client who is having surgery. The nurse notes that the client’s chart identifies a past history of narcotic drug abuse, but this was not verbalized by the client during the preoperative teaching. Which of the following actions is most appropriate for the nurse to consider when planning the client’s care?

The nurse is caring for a client who was admitted to the unit for treatment of anorexia nervosa. Which tasks can appropriately be delegated to the unlicensed assistive personnel (UAP) by the registered nurse? Select All That Apply 

The nurse is caring for a client and inquires about the client’s substance abuse. The client states, “It’s not really my fault, the reason I use drugs is because my partner is so annoying and constantly nagging me.”  Which potential defense mechanism does the nurse recognize the client may be using regarding their substance abuse?  

A nurse is continuing to care for the client on day 7. Nurses’ Notes Diagnostic Results Vital Signs  History and Physical Day 1, 1000: Client is an 18-year-old female, brought in by parent who reports client has not been eating well for several months and has lost 9 kg (20 lb). Client states, “I don’t want to eat because I will gain weight. I feel so fat.”  Client reports loss of appetite and admits to inducing vomiting after meals. Client is emaciated in appearance and has edema of the lower extremities and lanugo. Reports last menstrual period was 6 months ago.  Client is 160 cm (63 in) tall, and today’s weight is 40 kg (88 lb). BMI 15.6 Client is a senior in high school and is on the track team. Requests friends be allowed to come visit. Day 2, 0700: Client refuses to eat breakfast. Client has flat affect, wants to stay in bed and refuses to get dressed. Client states, “Everything is hopeless, I want it all to end.” 12 hour intake was 230 mL, output was 260 mL. Today’s weight is 39.5 kg (87 lb). Day 3, 0630: Today’s weight is 39.5 kg (87 lb).0830: Client consumed 20% of breakfast. Client has poor skin turgor and flat affect.Day 7, 0630: Weight 40.1 kg (88.5 lb)0830: Client consumed 50% of breakfast and 120 mL (4 oz) of liquid supplement.  Reports difficulty sleeping and frequent waking during the night. Requesting to go back to bed and sleep, flat affect noted with slow, quiet speech. Client refused to attend group and individual therapy sessions yesterday, spent most of the day in bed. Has not showered or changed clothes in two days. Day 1, 1030: Basic metabolic profile (BMP):Sodium 152 mEq/L (136 to 145 mEq/L)Potassium 3.1 mEq/L (3.5 to 5 mEq/L)Calcium 9.5 mg/dL (7.6 to 10.4 mg/dL)Phosphate 2.8 mg/dL (3 to 4.5 mg/dL)Magnesium 1.1 mEq/L (1.3 to 2.1 mEq/L)Hgb 16 g/dL (12 to 16 g/dL)Hct 46% (37% to 47%)Day 1, 1030: ECG:  Brady dysrhythmia Day 2, 0630: BMP: Sodium 146 mEq/L (136 to 145 mEq/L)  Potassium 3.5 mEq/L (3.5 to 5 mEq/L)   Calcium 9.5 mg/dL (7.6 to 10.4 mg/dL) Phosphate 2.9 mg/dL (3 to 4.5 mg/dL) Magnesium 1.3 mEq/L (1.3 to 2.1 mEq/L)   Day 3, 0830: BMP: Sodium 150 mEq/L (136 to 145 mEq/L)  Potassium 3.3 mEq/L (3.5 to 5 mEq/L)   Calcium 9.5 mg/dL (7.6 to 10.4 mg/dL) Phosphate 2.8 mg/dL (3 to 4.5 mg/dL) Magnesium 1.1 mEq/L (1.3 to 2.1 mEq/L)Day 7, 0630: BMP: Sodium 145 mEq/L (136 to 145 mEq/L)  Potassium 3.5 mEq/L (3.5 to 5 mEq/L)   Calcium 9.5 mg/dL (7.6 to 10.4 mg/dL) Phosphate 3.1 mg/dL (3 to 4.5 mg/dL) Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L) Vital Signs Day 1, 1000:Temperature 35.5° C (95.9° F)Heart rate 50/minRespiratory rate 18/minBlood pressure 88/60 mm HgSaO2 94% on room air Day 2, 0700: Temperature 35.8° C (96.4° F) Heart rate 54/min Respiratory rate 16/min Blood pressure 84/52 mm Hg SaO2 96% on room air Day 3, 0830: Temperature 35.5° C (95.9° F) Heart rate 50/min Respiratory rate 16/min Blood pressure 90/64 mm Hg SaO2 95% on room airDay 7, 0830: Temperature 36.1° C (97° F) Heart rate 62/min Respiratory rate 18/min Blood pressure 92/60 mm Hg SaO2 96% on room air    History & Physical Day 1,1000: Tonsillectomy 13 years agoDenies use of alcohol and drugsNonsmoker The nurse is evaluating the client’s progress toward meeting treatment goals after one week of treatment. Which of the following findings indicates the client’s condition is improving? 

The nurse is caring for an adolescent client who was admitted to the unit for nutritional support related to their diagnosis of anorexia nervosa. The client is mildly dehydrated, has a potassium level of 3.4 mEq/L (reference range: 3.5-5.0 mEq/L), and has experienced weight loss of more than 25% of their body weight within the past 3 months. What does the nurse identify as the primary goal for this client?  

The nurse is caring for a client who has a diagnosis of severe Generalized Anxiety Disorder and has a history of substance abuse. The client presented to the emergency department and has been prescribed lorazepam 2 mg IV push every 4 hours as needed for anxiety.  The nurse enters the client’s room to reassess them 15 minutes following administration of the prescribed lorazepam. Based on the nurse’s findings below, which action is most appropriate by the nurse at this time? Vital Signs  Physical Assessment  Temperature: 97.6 F Pulse: 58, weak   Respirations: 8, shallow   Blood Pressure: 110/74 Client is difficult to arouse  Client responds to verbal stimuli Slurred speech noted when aroused  Client confused, unable to recall information from initial assessment