1.The nurse auscultates crackles throughout all lung fields and measures a heart rate of 132 bpm, a respiratory rate of 30, and blood pressure of 102/54 mm Hg in a client recovering from an esophagectomy. Which action will the nurse take first?
1.Place the client on continuous pulse oximetry.
2.Monitor the client for changes in blood pressure. 3. Notify the health care provider.
4. Assist the client to use the incentive spirometer.
2.The nurse assigns a client diagnosed with cancer who is receiving chemotherapy to a nursing assistive personnel (NAP). Which instruction is most important for the nurse to include?
1.Perform hand hygiene frequently.
2.Wear a mask when entering the room.
3.Monitor the roommate for signs of infection.
4.Monitor the amount of protein the client eats.
3.The nurse provides care for a client diagnosed with a bone infection. The client was given intravenous morphine 3 hours ago and cannot have another dose for an hour. The client reports pain that is rated as 6 out of 10. The nurse implements several nonpharmacological approaches. The client’s pain level is now a 3 out of 10. Which action should the nurse take next?
1.Notify the health care provider.
2.Administer the morphine early.
3.Instruct the client that the next dose cannot be given for an hour. 4. Ask the client what is an acceptable pain level.
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