A client presents to the L&D unit screaming “the baby is coming!” Which action should the nurse implement first?
Observe the perineum
An adult male received a liver transplant a week ago. The nurse notes that he has developed a rash on his palms that itch and hurt. Which finding of GVHD is most important for the nurse to report to the healthcare provider?
WBC and differential count
A male client is returned to the surgical unit following a left kidney removal. The patient has a drain that is draining bloody drainage. The nurse should monitor output hourly
A client with cirrhosis and hepatic encephalopathy ascites resulting in portal hypertension. Which finding provides the nurse with an early indication that the client is at risk for a life-threatening complications?
Hematemesis and melena
Which assessment finding is indicative of a developing epidural hematoma?
Altered consciousness within the first 24 hours after injury
A client who is admitted with an ACS receives a glycoprotein inhibitor. Which assessment finding places the client a greatest risk?
Unresponsive to pain stimuli
Late decelerations intervention
Administer oxygen to the mother via face mask first
A female client with breast cancer who completed her first chemotherapy treatment today at an out-patient cancer treatment center is preparing for discharge. Which behavior indicates that the client understands her care needs for the next week?
Rented movies and borrowed books to use while passing time at home
A client receiving chemotherapy has severe neutropenia. Which snack is best for the nurse to recommend for this client?
Baked apples topped with dried raisins
The nurse has received funding to design a health promotions project for AA women are at risk for breast cancer. Which resource is most important in designing this program?
Participation of community leaders in planning the program
The nurse is starting an insulin infusion for a client with